Chapter 33 Flashcards
During the newborn examination, the nurse assesses for signs of developmental dysplasia of the hip. Which finding would strongly suggest this disorder?
- Asymmetric thigh and gluteal folds
- A positive Babinski reflex
- A negative Moro reflex
- Flat soles with prominent fat pads
1
The nurse is taking a health history from the family of a 3-year-old child. Which statement or question by the nurse would be most likely to establish rapport and elicit an accurate response from the family?
- “Tell me about the concerns that brought you to the clinic today.”
- “Does any member of your family have a history of asthma, heart disease, or diabetes?”
- “Hello, I would like to talk with you and get some information about you and your child.”
- “You will need to fill out these forms; make sure that the information is as complete as possible.”
1
A nurse working in the nursery notes that a newborn is having frequent episodes of apnea lasting 10 to 15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate?
- Continue to observe and call the healthcare provider if the apnea lasts longer than 20 seconds.
- Suction the mouth and nares.
- Call the healthcare provider immediately.
- Turn the newborn to the right side.
1
The nurse is completing a physical examination of a 4-year-old girl. Which is the best position to place the child in to assess the genitalia?
- Supine, with legs at a 50-degree angle
- Right side-lying
- In prone position, with knees drawn up under the body
- Frog-legged position
4
Which is the correct order for the nurse to conduct a physical assessment for a toddler-age client? Place in order from first assessment to last assessment.
- Auscultation of chest
- Examination of eyes, ears, and throat
- Palpation of abdomen
- General appearance
4,1,3,2
The nurse prepares to conduct a quick evaluation of a 1-month-old infant’s hearing. Which action will provide the best information?
- Examining the child’s ear canal with an otoscope
- Using a vibrating tuning fork placed against the child’s skull
- Using tympanometry to assess the child’s hearing
- Using a noisemaker to evaluate the child’s response
4
Which action by the nurse is appropriate when selecting a cuff to accurately assess blood pressure (BP) on a child?
- Select based on the label—infant, child, adult.
- Select based on a bladder that covers two thirds of the upper arm and wraps around at least 80% of the arm circumference.
- Select based on availability.
- Select based on a bladder that covers one fourth of the arm circumference and 50% of the upper arm.
2
While assessing a school-age child, the nurse notices a regular–irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. Which nursing action is appropriate based on these data?
- Record the finding as normal.
- Notify the healthcare provider.
- Schedule an electrocardiogram (ECG) immediately.
- Ask the mother if a murmur has been detected before.
1
While assessing the blood pressure of a school-age child, the nurse notes the following: Systolic sound is heard at 98, but the sound continues until it reaches 0. There is a distinct sound softening at 48. How should the nurse record this finding?
- 98/48
- 98/48/0
- 98/0
- 48/0
2
Which would the nurse consider as normal during a newborn assessment? Select all that apply.
- Swelling over the occiput that crosses suture lines
- Tiny white papules located primarily on the nose and chin
- Tiny red macules and pustules that come and go, primarily on the trunk and extremities
- When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest.
- Greenish discoloration of skin over the entire body that is not removed by the initial bath
1,2,3
The nurse is conducting an admission assessment for a newborn client. Which physical findings suggest the newborn is preterm? Select all that apply.
- The ear pinna quickly returns to original position after being bent manually.
- The infant’s resting position is tightly flexed.
- Labia are widely separated with clitoris prominent.
- Breast area is barely perceptible with flat areola, no bud.
- Sole creases do not extend the length of the foot.
3,4,5
The nurse is conducting a health history for the family of a 3-year-old child. Which statements or questions by the nurse would establish rapport and elicit an accurate response from the family? Select all that apply.
- “Hello, I would like to talk with you and get some information on you and your child.”
- “Does any member of your family have a history of asthma, heart disease, or diabetes?”
- “Tell me about the concerns that brought you to the clinic today.”
- “You will need to fill out these forms; make sure that the information is as complete as possible.”
- Asking the child, “What is your doll’s name?”
3,5
Which question from the nurse during a health history and physical assessment for the school-age child would best determine cognitive development?
- “What grade are you in?”
- “What is your least favorite class?”
- “What books have you read lately?”
- “What classes are you taking, and what are your grades in them?”
4
While assessing a 10-month-old infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would require more in-depth assessment based on this finding?
- Hepatic
- Cardiac
- Genitourinary
- Respiratory
1
During a routine physical assessment for a 9-month-old client, the nurse notes swelling in the ankles. The nurse presses against the ankle bone for 5 seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation. Which system requires a more in-depth assessment based on these data?
- Renal system
- Musculoskeletal system
- Respiratory system
- Integumentary system
1
