ATI Unit 1 - Cahpter 2

Question 1

What are some nursing considerations when performing a physical assessment?

Answer 1

1) keep room warm and well lit
2) move medical equipment out of sight
3) provide privacy (determine whether caregiver should stay in room for school-aged and adolescents)
4) explain each step with age-appropriate language, encourage to use equipment on others
5) examine child in secure position eg toddler may sit on parent’s lap
6) encourage questions/organized sequence

Question 2

Expected Temperature ranges for children (Age, recommended routes, expected level)

Answer 2

1) 3 months, 6 months, 1 year - axillary and rectal (if exact measurement needed)
3 months - 37.5C (99.5)F
6 months - 37.5C
1 year - 37/7C (99.9F)

2) 3 years, 5 years - axillary, tympanic, oral (if cooperative), rectal (if exact needed)
3 years- 37.2C (99)
5 years - 37.0C (98.6)

3) 7 years, 9 years, 11 years, 13 years - oral, axillary, tympanic
7 years - 36.8C (98.2F)
9 years - 36.7C
11 years - 36.7C
13 years - 36.6C

Question 3

Pulse rate ranges

Answer 3

Newborn - 80-180/min
1 week - 3 months - 80-220/min
3 months - 2 years: 70-150/min
2 - 10 years : 60-110/min
10 years and up: 50-90/min

Question 4

Respiration ranges

Answer 4

Newborn-1year: 30-35
1-2years: 25-30
2-6 years: 21-25
6-12 years: 19-21
12 years and older: 16-19

Question 5

BP measurements

Answer 5

Infants: 65-80/40-50
1 years: Girls (83-114/38-67); Boys (80-114/34-66)
3 years: Girls (86-117/47-76); Boys (86-120/44-75)
6years: Girls (91-122/54-83); Boys (91-125/53-84)
10 years: Girls (98-129/59-88); Boys (97-130/58-90)
16 years: Girls (108-138/64-93); Boys (111-145/63-94)

Question 6

At what age is erect head posture expected?

Answer 6

after 4 months of age, so before don’t necessarily have head control

Question 7

hair that is stringy, dull, brittle, and dry could be a sign of what?

Answer 7

nutritional deficiency

Question 8

hair loss or balding spots on infants may indicate what?

Answer 8

spending too much time in the same position

Question 9

when does the posterior fontanel close? anterior?

Answer 9

posterior: between 6 and 8 weeks of age
anterior: between 12 and 18 months

Question 10

how do you check for visual acuity in infants? children unable to read number and letters? older children?

Answer 10

visual acuity difficult to measure in children younger than 3
in infants: hold object in front of eyes and see if distracted and can fix on it
unable to read: use tumbling E or HOTV test
older children: Schnellen or symbol chart

Question 11

how can you assess color vision in children?

Answer 11

• Ishihara color test or the Hardy-Rand-Rittler test; child should correctly identify shapes, symbols, and numbers

Question 12

What are the findings for the peripheral visual fields?

Answer 12

Upward - 50 degrees
Downward - 70 degrees
Nasally - 60 degrees
Temporally - 90 degrees

Question 13

are extraocular movements always symmetric in newborns?

Answer 13

no

Question 14

when does permanent color manifest in the iris?

Answer 14

6-12 months

Question 15

is the red reflex present in infants?

Answer 15

yes

Question 16

How do you examine the inner ear for infants/toddlers?

Answer 16

pull the pinna down and back, for children older than 3 years of age pull the pinna up and back

Question 17

how can you assess hearing in an infant? newborns?

Answer 17

• infants should turn towards sounds

- newborns have intact acoustic blink reflexes to sudden sounds

Question 18

what’s important to know when examining an infant’s tongue?

Answer 18

• can have white coat from milk that can be easily removed, oral candidiasis coating not easily removed

Question 19

what should you know for teeth in infants? children?

Answer 19

• infants have 6-8 teetch by 1 year of age

- children and adolescents begin replacing the 20 deciduous teeth with 32 permanent teeth

Question 20

what’s the chest shape in infants? in children/adolescents?

Answer 20

infants - almost circular where anteroposterior diameter = transverse or lateral diameter

children/adolescents - ap diameter: transverse dia = 1:2

Question 21

between what ages do females usually develop breasts?

Answer 21

10-14 years of age

Question 22

What are the infant reflexes and expected ages?

Answer 22

1) sucking and rooting reflexes: elicited by stroking infan’ts cheek or edge of mouth (turns head towards and starts to suck) -> birth - 4 months
2) Palmar grasp: elicited by placing object in infant’s palm (infant grasps objects) -> birth to 3 months
3) Plantar graps touch infant’s foot sole (toes curl downward) -> birth to 8 months
4) Moro reflex: elicited by allowing head and trunk to fall backwards (infant arms and legs extend then abduct while fingers spread to form C shape) -> birth to 4 months
5) Startle reflex: clapping hand or loud noise (newborn will abduct arms at elbows and hands remain clenched) -> birth to 4 months
6) Tonic neck reflex or fencer position: elicited by tuning an infant’s head to one side (infant extends arm and leg on that side and flexes the arm and leg on opposite side): birth to 3-4 months
7) Babinski reflex: stroke outer edge of sole up towards toes (infants toes fan upward and out) -> birth to 1 year
8) Stepping: elicited by holding an infant upright with feet touching a flat surface (infant makes stepping movements) -> birth to 4 weeks

Question 23

know the cranial nerves p. 17

Answer 23

look up