Chapter 5: Pediatric Assessment Flashcards

Question

When taking a health history for a pediatric patient, which of the following demographic details would the nurse typically obtain? A. The child’s favorite color and hobbies. B. The child’s birth weight and Apgar score. C. The child’s name, age, sex, ethnic origin, and contact information. D. The child’s immunization history.

Answer 1

C. The child’s name, age, sex, ethnic origin, and contact information. Rationale: Demographic information includes the child’s name, age, sex, ethnic origin, and contact details, which are essential for identification and communication.

Answer 2

B. The expected date of birth and any complications during pregnancy. Rationale: Prenatal conditions such as the expected date of birth, health during pregnancy, and any complications are critical to understanding potential risks or issues for both the mother and baby.

Answer 3

B. All past major illnesses, injuries, and common communicable diseases. Rationale: The health history should include a comprehensive record of all major past illnesses, injuries, and communicable diseases to provide a full understanding of the child’s health.

Answer 4

C. The name, relationship, and phone number of the emergency contact. Rationale: Emergency contact information includes the name, relationship to the child, and phone number, which is crucial in case of an emergency.

Answer 5

A. The birth weight, Apgar score, and any need for special care such as resuscitation or oxygen. Rationale: The condition of the baby at birth is documented through the birth weight, Apgar score, and any need for immediate care, which helps assess the infant’s health status at delivery.

Answer 6

B. Use the child’s or parent’s exact words to describe the primary concern. Rationale: The chief concern should be documented using the exact words of the parent or child to accurately capture their perception of the problem and avoid misinterpretation.

Answer 7

A. Document the child's primary problem as respiratory distress and proceed with a focused respiratory assessment. Rationale: Answer B is correct because it emphasizes the importance of using the parent's exact words when documenting the child's primary problem. This ensures accuracy and clarity in communication. Additionally, informing the physician immediately is crucial to ensure that the child receives timely and appropriate medical intervention for the potential respiratory distress.

Answer 8

A) Primary healthcare provider visits C) Dentist visits D) Timing of last specialty healthcare provider visit Rationale: Health maintenance involves regular visits to the child’s primary healthcare provider, dentist, and other specialty healthcare providers. It does not typically include over-the-counter medication use or the frequency of physical exercise.

Answer 9

C) The use of complementary therapies such as herbs and teas Rationale: It is important to ask about the use of herbs, plants, teas, or other complementary therapies that might interact with prescribed or over-the-counter medications.

Answer 10

B) Dates immunizations were received Rationale: Reviewing the dates immunizations were received and asking about any unexpected reactions are crucial components of assessing a child’s immunization history.

Answer 11

D) Allergies Rationale: Respiratory difficulty after exposure to certain foods is a common symptom of an allergy, which should be documented and managed appropriately.

Answer 12

A) Usual play and/or sports activities B) Physical mobility and limitations C) Use of adaptive equipment Rationale: Assessing the child's usual play and/or sports activities, physical mobility and limitations, and the use of adaptive equipment are important aspects of understanding the child's level of physical activity and exercise.

Answer 13

C) The recommended amount for age and weight Rationale: The child's food intake should be compared to the appropriate amount for their age and weight to ensure they are receiving proper nutrition.

Answer 14

A) Chronic diseases experienced by grandparents C) History of hereditary conditions in aunts and uncles E) Genetic disorders in the child Rationale: To comprehensively understand familial diseases, the nurse should gather information about chronic diseases in grandparents, hereditary conditions in aunts and uncles, and any genetic disorders in the child. The current medications of siblings and the marital status of cousins are less relevant to familial disease history.

Answer 15

A) Family members living in the home C) Marital status of the parents D) People helping to care for the child Rationale: Documenting family members living in the home, the marital status of the parents, and people helping to care for the child provides critical information for understanding the child's support system.

Answer 16

A) Household members employed C) Types of healthcare resources available Rationale: Assessing household members employed and types of healthcare resources (e.g., private insurance, Medicaid) helps determine the family's financial stability and ability to access healthcare.

Answer 17

A) Housing condition C) Potential lead exposure D) Availability of heat and refrigeration Rationale: The nurse should investigate the housing condition, potential lead exposure, and availability of heat and refrigeration to understand the child’s living environment and identify any risks.

Answer 18

C) Family or lifestyle changes Rationale: Recent unemployment and relocation are examples of family or lifestyle changes that can affect the child's psychosocial health and the family’s coping mechanisms.

Answer 19

A) Support for the parent in the initial postpartum period B) Safe transport C) Availability of heat and safe water supplies Rationale: Ensuring support for the parent, safe transport, and the availability of heat and safe water supplies are essential for the newborn’s well-being and the parents’ readiness to care for the newborn at home.

Answer 20

B) Daily routines C) Psychosocial data impacting quality of daily living Rationale: Focusing on the child's daily routines and psychosocial data that impact the quality of daily living provides a comprehensive understanding of the child's needs and any potential issues.

Answer 21

A) Home environment B) Education and employment C) Activities D) Substance abuse Rationale: The HEEADSSS screening tool includes key topics such as home environment, education and employment, activities, and substance abuse to assess critical areas in adolescents' lives that may impact their growth and development.

Answer 22

B) Fine and gross motor skills Rationale: Assessing fine and gross motor skills provides crucial information about a child's motor development.

Answer 23

B) Parent questionnaire Rationale: A parent questionnaire can be used to collect information about a child's language development, including the age at which the child first used words and their current language ability.

Answer 24

A) Foot-to-head Rationale: In young children, a foot-to-head sequence is often used so that the least distressing parts of the examination are completed first.

Answer 25

C) To auscultate the lungs, heart, and abdomen while the child is asleep or quiet Rationale: Experienced examiners often vary the examination sequence to auscultate the lungs, heart, and abdomen when an infant or toddler is asleep or quiet, ensuring accurate assessment without causing distress.

Answer 26

D) Purposeful observation of physical features and behaviors Rationale: Inspection involves purposeful observation of the child's physical features and behaviors during the entire physical examination. It includes characteristics such as size, shape, color, movement, position, and location.

Answer 27

A) Stethoscope Rationale: Auscultation is usually performed with a stethoscope to enhance the sounds heard in the chest and abdomen.

Answer 28

A) Feeding B) Using a pacifier C) Cuddling Rationale: Keeping the parent present to provide comfort through feeding, using a pacifier, and cuddling helps keep the infant calm and quiet during the examination.

Answer 29

C) When the infant is quiet or asleep Rationale: The best time to auscultate lung, heart, and abdominal sounds is when the infant is quiet or asleep to obtain accurate assessment without causing distress.

Answer 30

D) Examination of the hips Rationale: The examination of the hips should be performed last as it may disturb the infant. This allows for the less distressing parts of the examination to be completed first.

Answer 31

A) On the parent’s lap Rationale: Due to developing separation and stranger anxiety, it is best to examine the infant on the parent’s lap to provide comfort and security.

Answer 32

C) Make sure the room is warm Rationale: Ensuring the room is warm makes the infant comfortable during the examination, especially when clothing is removed.

Answer 33

B) Begin with the feet and hands Rationale: To reduce fear, it is recommended to begin the examination with the feet and hands before moving to the trunk.

Answer 34

A) Use toys B) Smile and talk soothingly C) Use a pacifier or bottle Rationale: Using toys, smiling and talking soothingly, and providing a pacifier or bottle are effective techniques to keep an older infant calm and distracted during the examination.

Answer 35

C) Demonstrate the use of instruments on the parent or security object Rationale: Demonstrating the use of instruments on the parent or security object helps to reduce the toddler's anxiety by making the examination process familiar and less intimidating.

Answer 36

D) Have the parent hold the child close to their chest Rationale: For invasive procedures like ear and mouth examinations, having the parent hold the child close to their chest helps to provide comfort and security, reducing anxiety for the toddler.

Answer 37

B) Observing the child play and walk around the examining room Rationale: Observing the child play and walk around the examining room allows the nurse to perform much of the neurologic and musculoskeletal assessment in a natural and non-intrusive manner.

Answer 38

B) The typical response from the toddler will be "No" Rationale: Asking a toddler for permission to perform a part of the examination often results in a "No" response. Instead, the nurse should confidently tell the child what will be done next, which helps to set clear expectations and gain cooperation.

Answer 39

A) By observing the child's comfort level when sitting on the examining table Rationale: The nurse should assess the willingness of the child to be separated from the parent by observing the child's comfort level when sitting on the examining table with the parent close by.

Answer 40

C) Using toys and providing simple explanations Rationale: Allowing the child to touch and play with the equipment, giving simple explanations about the assessment procedures, and using toys as distractions can help gain cooperation from the preschooler during the examination.

Answer 41

D) By giving positive feedback when the child cooperates Rationale: Giving positive feedback when the child cooperates reinforces good behavior and encourages the child to continue cooperating during the examination.

Answer 42

B) Head-to-toe Rationale: A head-to-toe sequence is appropriate for school-age children, allowing for a systematic and thorough examination.

Answer 43

A) By offering as many choices as possible Rationale: Offering as many choices as possible helps the school-age child feel empowered and involved in their own care.

Answer 44

A) Provide reassurance about the normal progression and expected changes Rationale: Adolescents often have concerns about their developing bodies, and providing reassurance about the normal progression of secondary sexual characteristic development and expected changes is important.

Answer 45

B) The child's general appearance and behavior Rationale: Observing the child's general appearance and behavior helps the nurse assess whether the child appears well-nourished, well-developed, and secure with their parent.

Answer 46

C) To provide a basis for medication dosages and fluids Rationale: Accurate measurement of the infant's weight, length, and head circumference is important for determining medication dosages and fluid needs, ensuring proper care based on the child's growth parameters.

Answer 47

A) To detect variations in skin color and identify lesions Rationale: Good lighting is essential for detecting variations in skin color and identifying lesions during the examination of a child's skin.

Answer 48

C) Buccal mucosa and tongue Rationale: In darker-skinned children, the buccal mucosa and tongue should be inspected to confirm a suspected skin color abnormality because these areas are usually pink regardless of skin color.

Answer 49

D) Respiratory and cardiac disorders Rationale: Generalized cyanosis in a child is associated with respiratory and cardiac disorders, indicating a lack of oxygen in the blood.

Answer 50

B) They could indicate child abuse Rationale: Bruises found on other parts of a child's body, especially in various stages of healing, should raise suspicion of child abuse, as they may not be typical bruising from normal activities.

Answer 51

A) Freckles and Mongolian spots Rationale: Freckles are common in the white population, while Mongolian spots are hyperpigmented patches commonly seen in Native American, Asian, Black, and Hispanic infants and are considered a normal variation.

Answer 52

C) Spinal defect Rationale: A tuft of hair at the base of the spine often indicates a spinal defect and should be further investigated.

Answer 53

B) Hair loss may be due to tight braids or ringworm, and a low hairline may indicate hypothyroidism Rationale: Variation in hair color can indicate nutritional deficits, hair loss may be from tight braids or skin lesions like ringworm, and an unusually low hairline may indicate a congenital disorder like hypothyroidism.

Answer 54

A) To confirm the abnormality in lighter skin areas Rationale: Inspecting the buccal mucosa and tongue helps confirm skin color abnormalities, as these areas are usually pink regardless of skin color, making it easier to detect changes like jaundice or cyanosis in darker-skinned children.

Answer 55

D) Kidney or heart disorders Rationale: Pitting edema, which is observed by pressing against a bone beneath a puffy area of skin, is commonly associated with kidney or heart disorders.

Answer 56

C) Dehydration, hypovolemic shock, or physical constriction Rationale: A prolonged capillary refill time, which should normally be less than 2 seconds, indicates potential dehydration, hypovolemic shock, or physical constriction (such as from a cast or bandage).

Answer 57

A) Initial response to injury or infection Rationale: Primary lesions, such as macules, papules, and vesicles, are often the skin’s initial response to injury or infection.

Answer 58

B) Mongolian spots and freckles Rationale: Hyperpigmented patches (Mongolian spots) and freckles are normal findings classified as primary lesions.

Answer 59

B) Result of irritation, infection, and delayed healing of primary lesions Rationale: Secondary lesions, such as scars, ulcers, and fissures, are the result of irritation, infection, and delayed healing of primary lesions.

Answer 60

C) Inspect and palpate the isolated or generalized skin areas Rationale: Inspecting and palpating the isolated or generalized skin color abnormalities, elevations, lesions, or injuries help describe all characteristics present, providing a clearer understanding of the condition.

Answer 61

A) Flat, nonpalpable, diameter less than 1 cm

Answer 62

A) Impetigo Rationale: A pustule is a vesicle filled with purulent fluid, and impetigo is a common example of such a lesion.

Answer 63

C) Hair color variation not caused by bleaching or coloring Rationale: Variation in hair color not caused by bleaching or coloring may be associated with a nutritional deficiency.

Answer 64

B) Tight braids or skin lesions such as ringworm Rationale: Hair loss in a child may result from tight braids or skin lesions such as ringworm, which can cause damage to the hair follicles.

Answer 65

A) Hypothyroidism Rationale: An unusually low hairline on the neck or forehead may be associated with a congenital disorder such as hypothyroidism.

Answer 66

D) It may indicate a spinal defect Rationale: A tuft of hair at the base of the spine often indicates a spinal defect and should be further investigated.

Answer 67

C) Increased intracranial pressure Rationale: A tense fontanelle that bulges above the margin of the skull is an indication of increased intracranial pressure.

Answer 68

C) Skull fracture Rationale: Feeling additional bone edges along the suture lines can indicate a skull fracture.

Answer 69

D) Abnormal skull shape Rationale: Premature closure of the sutures can result in an abnormal skull shape.

Answer 70

B) The weight of the head flattening soft skull bones early in infancy Rationale: A flat, elongated skull in low-birth-weight infants is often caused by the soft skull bones being flattened by the weight of the head early in infancy.

Answer 71

B) Dehydration Rationale: A sunken fontanelle below the margin of the skull is associated with dehydration.

Answer 72

D) Ask for permission before touching the infant’s head Rationale: The head is considered a sacred part of the body to some Southeast Asians, so it is important to ask for permission before touching the infant’s head to palpate the sutures and fontanelles.

Answer 73

A) Paralysis of trigeminal or facial nerves, in utero positioning, or swelling from infection, allergy, or trauma Rationale: Significant asymmetry may result from paralysis of trigeminal or facial nerves (cranial nerves V or VII), in utero positioning, and swelling from infection, allergy, or trauma.

Answer 74

C) Seizures Rationale: Tremors, tics, and twitching of facial muscles are often associated with seizures and should be further investigated.

Answer 75

B) Hypertelorism Rationale: Hypertelorism refers to widely spaced eyes, which can be a normal variation in some individuals.

Answer 76

D) Muscle imbalance Rationale: An asymmetric corneal light reflex in a child older than 6 months indicates a muscle imbalance that may require further evaluation.

Answer 77

A) Eye bulging B) Retracted eyelids C) Sunken appearance Rationale: Observing for eye bulging (which may indicate a tumor), retracted eyelids, and a sunken appearance (which may indicate dehydration) are important steps in identifying possible underlying conditions affecting the eyes.

Answer 78

D) Swelling or inflammation along the edges Rationale: Eyelids should be the same color as surrounding facial skin and free of swelling or inflammation along the edges to indicate a healthy condition.

Answer 79

A) Injury to the oculomotor nerve (cranial nerve III) Rationale: Ptosis, or drooping of the lid over the pupil, is often associated with injury to the oculomotor nerve (cranial nerve III).

Answer 80

D) Increased intracranial pressure or hydrocephalus Rationale: The "sunset sign," where the sclera is seen persistently between the upper lid and the iris, may indicate hydrocephalus or increased intracranial pressure.

Answer 81

B) Upward palpebral slant C) Epicanthal fold Rationale: An upward palpebral slant is a normal finding in Asian children and is also common in children with Down syndrome. Additionally, children of Asian descent often have an epicanthal fold, an extra fold of skin covering all or part of the lacrimal caruncle.

Answer 82

B) Jaundice Rationale: Yellow sclerae suggest the presence of jaundice, indicating a possible underlying liver condition.

Answer 83

D) Genetic syndrome, such as Down syndrome Rationale: Brushfield spots, which are white specks in a linear pattern around the iris circumference, are often associated with Down syndrome.

Answer 84

A) Eyestrain, allergies, or irritation Rationale: Redness in the bulbar conjunctivae can indicate eyestrain, allergies, or irritation, and should be further investigated to determine the cause.

Answer 85

C) Other congenital anomalies Rationale: A coloboma, which is a keyhole-shaped pupil caused by a notch in the iris, can indicate that the child has other congenital anomalies.

Answer 86

B) Pupil constriction with near objects and pupil dilation with distant objects Rationale: The expected response when testing pupillary accommodation is pupil constriction with near objects and pupil dilation with distant objects.

Answer 87

C) Muscle imbalance causing eyes to look crossed, leading to potential vision impairment Rationale: Strabismus is a muscle imbalance that makes the eyes look crossed and can cause vision impairment if uncorrected, making it important to detect early.

Answer 88

B) Cranial nerves III, IV, and VI Rationale: The oculomotor, trochlear, and abducens nerves (cranial nerves III, IV, and VI) are tested when evaluating extraocular movements.

Answer 89

C) Muscle imbalance Rationale: An asymmetric corneal light reflex in a child older than 6 months indicates a muscle imbalance that may require further evaluation and potential correction.

Answer 90

A) Starting at about 5 years old; indicates a muscle imbalance Rationale: The cover–uncover test is typically used starting at about 5 years old for older, cooperative children. Eye movement during this test indicates a muscle imbalance.

Answer 91

C) Older, cooperative children starting at about 5 years old Rationale: The cover–uncover test is typically used for older, cooperative children starting at about 5 years of age.

Answer 92

C) Muscle imbalance Rationale: Eye movement during the cover–uncover test indicates a muscle imbalance, which may require further evaluation and potential correction.

Answer 93

C) Blindness Rationale: An absent blink reflex can indicate that the infant is blind.

Answer 94

A) The infant's eyes move to follow the object Rationale: The normal response is for the infant's eyes to move to follow the object.

Answer 95

C) HOTV, Snellen E, and Picture charts Rationale: The HOTV, Snellen E, and Picture charts are used to test visual acuity in preschool-age children.

Answer 96

D) 10 or 20 feet Rationale: Children are usually placed 10 or 20 feet from the vision chart during standardized vision testing.

Answer 97

A) When a 3-year-old does not correctly identify most images on the 20/50 line Rationale: A child should be referred for further vision assessment when a 3-year-old does not correctly identify most images on the 20/50 line, a 4-year-old on the 20/40 line, and a 5-year-old on the 20/32 line.

Answer 98

B) The vascular retina's orange-red glow Rationale: The red reflex test evaluates the orange-red glow of the vascular retina when light travels through the cornea, aqueous humor, lens, and vitreous humor to the retina.

Answer 99

B) Congenital cataracts, hemorrhage, or corneal scars Rationale: Black spots or opacities within the red reflex may indicate congenital cataracts, hemorrhage, or corneal scars.

Answer 100

B) Tumor or retinoblastoma Rationale: A white reflex is associated with a tumor or retinoblastoma and requires further investigation.

Answer 101

A) Pull the pinna down and back Rationale: To straighten the auditory canal in children under 3 years of age, the pinna should be pulled down and back.

Answer 102

D) Congenital renal disorders Rationale: A low-set pinna is often associated with congenital renal disorders and should prompt further investigation.

Answer 103

D) Infection in the mastoid process of the temporal bone of the skull Rationale: Swelling behind the ear with a protruding pinna may indicate an infection in the mastoid process of the temporal bone of the skull.

Answer 104

B) Foreign body or infection in the external canal Rationale: A foul-smelling, purulent discharge from the external auditory canal may indicate the presence of a foreign body or an infection in the external canal.

Answer 105

B) The tympanic membrane may be ruptured, allowing water to enter the middle ear and potentially worsen the infection Rationale: B) The tympanic membrane may be ruptured, allowing water to enter the middle ear and potentially worsen the infection

Answer 106

A) They are prone to otitis media, a middle ear infection Rationale: Examination of the tympanic membrane is important in infants and young children because they are prone to otitis media, a middle ear infection.

Answer 107

C) Rest the back of your hand holding the otoscope against the child's head Rationale: When the child is cooperative, rest the back of your hand holding the otoscope against the child's head to stabilize it, ensuring safety during the examination.

Answer 108

D) Pearly gray and translucent Rationale: The tympanic membrane is normally pearly gray and translucent, reflecting light, with the bones (ossicles) in the middle ear being visible.

Answer 109

D) The tympanic membrane may be ruptured, allowing water to enter the middle ear and potentially worsen the infection Rationale: Ear irrigation should be avoided if there is discharge in the auditory canal because the tympanic membrane may be ruptured, allowing water to enter the middle ear and potentially worsen the infection.

Answer 110

B) Perform warm water irrigation to clean the canal Rationale: If the auditory canal is obstructed by cerumen or a foreign body, warm water irrigation can be used to clean the canal, provided there is no discharge present.

Answer 111

A) Birth trauma, frequent otitis media, meningitis, or antibiotics that damage cranial nerve VIII Rationale: Hearing loss in early childhood can occur due to birth trauma, frequent otitis media, meningitis, or antibiotics that damage cranial nerve VIII.

Answer 112

A) No startle reaction to loud noises B) Babbles as a young infant but stops babbling or does not develop speech sounds after 6 months of age D) Speech sounds are not distinct at appropriate ages Rationale: Indicators of hearing loss in infants include no startle reaction to loud noises, babbling that stops or does not progress after 6 months, and indistinct speech sounds at appropriate ages.

Answer 113

B) To estimate the pressure in the middle ear and indirectly measure tympanic membrane movement Rationale: Tympanometry is used to estimate the pressure in the middle ear and is an indirect measure of tympanic membrane movement.

Answer 114

D) When a hearing deficiency is suspected as a result of screening, such as inability to follow age-appropriate directions or lack of distinct speech sounds Rationale: A child should be referred for audiometry when a hearing deficiency is suspected as a result of screening, such as inability to follow age-appropriate directions or lack of distinct speech sounds.

Answer 115

B) 60 cm (2 feet) Rationale: The noisemaker should be about 60 cm (2 feet) away from the infant's ear but outside the infant's field of vision to effectively test the infant's hearing.

Answer 116

A) Widening the eyes B) Briefly stopping all activity to listen C) Turning the head toward the sound Rationale: The responses that indicate an infant hears the noisemaker include widening the eyes, briefly stopping all activity to listen, and turning the head toward the sound.

Answer 117

A) Position your head about 30 cm (12 in.) away from the child’s ear, out of the range of vision, and use easily recognized words Rationale: For children over 3 years of age, a hearing test using whispered words should be conducted by positioning your head about 30 cm (12 in.) away from the child’s ear, out of their range of vision, and using words that are easily recognized by the child.

Answer 118

C) Use a whisper to ask the child to point to different body parts or objects while staying out of their line of sight Rationale: If the child does not repeat the whispered words, use a whisper to ask the child to point to different body parts or objects, ensuring you stay out of their line of sight to prevent lip reading.

Answer 119

A) The sound is heard equally in both ears Rationale: The normal response during the Weber test is for the sound to be heard equally in both ears.

Answer 120

C) Sound is heard longer by bone conduction than air conduction Rationale: Conductive hearing loss is indicated when the sound is heard longer by bone conduction than by air conduction in the Rinne test.

Answer 121

D) Sensorineural hearing loss Rationale: If the sound is heard longer by air conduction than bone conduction, but for less than twice as long, it indicates sensorineural hearing loss.

Answer 122

B) Use of hand to rub an itchy nose upward Rationale: A crease across the nose between the cartilage and bone is often caused when an allergic child uses a hand to rub an itchy nose upward.

Answer 123

B) Sign of respiratory distress Rationale: Nasal flaring, or the widening of the nares with breathing, is a sign of respiratory distress and should not be present in a healthy child.

Answer 124

C) Saddle-shaped nose Rationale: A saddle-shaped nose is commonly associated with congenital defects such as cleft palate.

Answer 125

B) No tenderness or masses Rationale: No tenderness or masses are expected when palpating the external nose. Pain and a contour deviation are usually the result of trauma.

Answer 126

A) By occluding one nostril and observing the child's effort to breathe through the open nostril with the mouth closed, then repeating on the other nostril Rationale: To test nasal patency, occlude one nostril and observe the child's effort to breathe through the open nostril with the mouth closed. Repeat on the other nostril. Breathing should be noiseless and effortless.

Answer 127

B) Nasal obstruction, possibly caused by a foreign body, congenital defect, dry mucus, discharge, polyp, or trauma Rationale: Unilateral nasal flaring in a young child may indicate nasal obstruction, which can be caused by a foreign body, congenital defect, dry mucus, discharge, polyp, or trauma.

Answer 128

B) Occlude one nostril, hold a recognizable scent under the nose, and ask the child to identify the scent Rationale: The procedure for testing the olfactory nerve involves occluding one nostril, holding a recognizable scent under the nose, and asking the child to identify the scent while alternating odors between the nares.

Answer 129

D) Allergies Rationale: Pale or bluish-gray turbinates are often associated with allergies.

Answer 130

D) Straight without perforations, bleeding, or crusting Rationale: The nasal septum should be straight without perforations, bleeding, or crusting. Crusting is usually noted over the site of a nosebleed.

Answer 131

B) Observe for watery, mucoid, purulent, or bloody discharge; normal only if the child is crying Rationale: Observe for watery, mucoid, purulent, or bloody discharge, which is not a normal finding unless the child is crying.

Answer 132

B) Sinusitis Rationale: Tenderness during palpation of the maxillary or ethmoid sinuses may indicate sinusitis.

Answer 133

A) Their breathing is not yet coordinated with mouth breathing Rationale: Newborns and infants under 6 months of age will not automatically open their mouths to breathe when their nose is occluded because their breathing is not yet coordinated with mouth breathing.

Answer 134

C) Flattened nasal bridge Rationale: A flattened nasal bridge is a normal finding in Asian and Black children and may also be seen in children with Down syndrome.

Answer 135

C) Nasal obstruction Rationale: Unilateral nasal flaring in a young child indicates a nasal obstruction, which may be caused by a foreign body, congenital defect, dry mucus, discharge, polyp, or trauma.

Answer 136

C) Congenital defects such as cleft palate Rationale: A saddle-shaped nose is associated with congenital defects such as cleft palate.

Answer 137

A) Dark pink and glistening Rationale: The mucous membranes should be dark pink and glistening.

Answer 138

D) By alternating easily recognized scents under each nostril while the child's eyes are closed Rationale: The olfactory nerve should be tested by occluding one nostril, holding a recognizable scent under the nose, and asking the child to identify the scent, alternating odors between the nares.

Answer 139

A) At birth, by 4 years, by 5 years, and by adolescence, respectively Rationale: The ethmoid sinuses are present at birth and air-filled, the maxillary sinuses are present at birth and become air-filled by 4 years of age, the sphenoid sinuses are present by 5 years of age, and the frontal sinuses form at about 7 to 8 years of age and are completely developed by adolescence.

Answer 140

B) Use a tongue blade to gently separate the teeth Rationale: If a young child resists a mouth/throat examination by clenching their teeth, a tongue blade can be used to gently separate the teeth.

Answer 141

A) When there are signs of respiratory distress, high fever, drooling, and intense apprehension Rationale: The examination of the mouth should be avoided if there are signs of respiratory distress, high fever, drooling, and intense apprehension as these may indicate epiglottitis, and inspecting the mouth may trigger a total airway obstruction.

Answer 142

C) Poor tissue perfusion caused by various conditions Rationale: Pale, cyanotic, or cherry-red lips indicate poor tissue perfusion caused by various conditions and require further evaluation.

Answer 143

B) Symmetric lips without drying, cracking, or lesions Rationale: The lips are normally symmetric without drying, cracking, or other lesions, and should be pink in White children and more bluish in darker-skinned children.

Answer 144

A) Abnormal odors, which could indicate problems such as diabetic ketoacidosis, infection, poor hygiene, or alcohol odors in older children that could signal substance abuse Rationale: Abnormal mouth odors, such as those associated with diabetic ketoacidosis, infection, or poor hygiene, should be noted. Additionally, alcohol odors in older children could signal substance abuse.

Answer 145

C) Pink with a stippled or dotted appearance Rationale: The gums are normally pink with a stippled or dotted appearance, and should adhere to the teeth without raised or receding areas.

Answer 146

D) Infection and poor nutrition Rationale: Inflammation and tenderness of the gums are associated with infection and poor nutrition.

Answer 147

B) Mumps infection Rationale: Redness at the Stensen duct opening, which is normally pink, indicates a possible mumps infection.

Answer 148

B) Genetic conditions, such as Down syndrome Rationale: A protuberant tongue is associated with genetic conditions, such as Down syndrome.

Answer 149

C) Thrush, a Candida infection Rationale: A white adherent coating on an infant’s tongue may indicate thrush, a Candida infection.

Answer 150

B) Ask the child to touch the gums above the upper teeth with their tongue, stick out the tongue, and lift it to assess the underside and floor of the mouth; to identify potential speech issues related to tongue movement Rationale: Assessing the mobility of a child's tongue by asking them to touch the gums above the upper teeth, stick out the tongue, and lift it to assess the underside and floor of the mouth is important to identify potential speech issues related to tongue movement.

Answer 151

D) Pink, dome-shaped palate with no cleft; uvula hanging freely from the soft palate Rationale: The palate is normally pink, dome-shaped, and has no cleft, with the uvula hanging freely from the soft palate.

Answer 152

C) Sucking difficulties Rationale: A high-arched palate can be associated with sucking difficulties in young infants.

Answer 153

A) By placing your index finger against the child’s cheek and asking the child to push against your finger with their tongue Rationale: The hypoglossal nerve (cranial nerve XII) is tested by placing your index finger against the child’s cheek and asking the child to push against your finger with their tongue. Normally, some pressure against the finger is felt.

Answer 154

D) Insert a gloved little finger, with the finger pad upward, into the mouth while the infant sucks; it assesses for any clefts and the strength of the sucking reflex innervated by the hypoglossal nerve (cranial nerve XII) Rationale: The procedure for palpating the palate involves inserting a gloved little finger, with the finger pad upward, into the mouth while the infant sucks. This assesses for any clefts and the strength of the sucking reflex innervated by the hypoglossal nerve (cranial nerve XII).

Answer 155

C) Local infections like mumps or congenital defects; the neck is normally symmetric without swelling Rationale: Swelling in a child's neck may be caused by local infections such as mumps or congenital defects. The neck is normally symmetric without swelling.

Answer 156

B) Associated with Turner syndrome; neck lengthens between 3 and 4 years of age Rationale: Webbing on each side of the neck is commonly associated with Turner syndrome. The neck typically lengthens between 3 and 4 years of age.

Answer 157

A) Firm, clearly defined, nontender, movable, up to 1 cm in diameter Rationale: Normal lymph nodes in young children are firm, clearly defined, nontender, movable, and up to 1 cm in diameter.

Answer 158

B) Local infection Rationale: Enlarged, firm, warm, tender lymph nodes indicate a local infection and warrant further investigation.

Answer 159

D) They have short necks Rationale: It is difficult to palpate the trachea in children less than 3 years of age because of their short necks.

Answer 160

B) When they are enlarged Rationale: The lobes of the thyroid are normally covered by the sternocleidomastoid muscle and are not usually palpable in a child unless they are enlarged.

Answer 161

A) Torticollis Rationale: Limited horizontal range of motion may be a sign of torticollis, which results from a birth injury to the sternocleidomastoid muscle or from unilateral vision or hearing impairment.

Answer 162

C) Meningitis Rationale: Pain with flexion of the neck toward the chest (Brudzinski sign) may indicate meningitis.

Answer 163

B) To ensure an unobstructed view of the chest for assessing thoracic muscles, subcutaneous tissue, chest wall thickness, and rib cage prominence Rationale: Positioning the child on the parent’s lap or on the examining table with all clothing above the waist removed ensures an unobstructed view of the chest, allowing for the assessment of thoracic muscles, subcutaneous tissue, chest wall thickness, and rib cage prominence.

Answer 164

D) Chronic obstructive lung conditions such as asthma or cystic fibrosis Rationale: By the age of 2 years, the chest should become more oval with growth, with the lateral diameter greater than the anteroposterior diameter. If a child over 2 years of age has a rounded chest, it may indicate chronic obstructive lung conditions such as asthma or cystic fibrosis, as these conditions can impact lung development and chest shape due to prolonged respiratory difficulty.

Answer 165

A) Pectus carinatum, pectus excavatum, scoliosis, and Turner syndrome Rationale: Abnormal chest shapes in children can result from structural deformities such as pectus carinatum (protrusion of the chest), pectus excavatum (sunken chest), and scoliosis (curvature of the spine), which causes a lateral deviation of the chest. Additionally, a shield-shaped chest, which is unusually broad with widely spaced nipples, can be associated with Turner syndrome, a genetic disorder that affects development.

Answer 166

C) Diaphragm, which is the primary muscle for ventilation in infants and young children; thoracic muscles become primary as they develop Rationale: The diaphragm is the primary muscle used for ventilation in infants and young children. As they grow and the thoracic muscles develop, these muscles become the primary muscles for ventilation.

Answer 167

D) Increased work of breathing and often respiratory distress due to partial airway obstruction Rationale: Retractions, which are visible depressions of tissue between the ribs of the chest wall with each inspiration, indicate an increased work of breathing and often respiratory distress due to partial airway obstruction. This is a sign that the child is using accessory muscles for inspiration, highlighting a need for further assessment and intervention.

Answer 168

B) Infants and young children use the diaphragm as the primary breathing muscle Rationale: In infants and young children, the diaphragm is the primary muscle used for breathing, making the rise and fall of the abdomen the best indicator of respiratory rate.

Answer 169

A) 30–55 breaths per minute Rationale: The normal respiratory rate range for a newborn is 30–55 breaths per minute.

Answer 170

D) Higher metabolic rate and oxygen requirement Rationale: Infants and children have a faster respiratory rate than adults due to their higher metabolic rate and oxygen requirement.

Answer 171

B) While the baby is sleeping or resting quietly Rationale: The most accurate reading of a young infant’s respiratory rate is obtained while the baby is sleeping or resting quietly.

Answer 172

A) Excitement, fear, respiratory distress, fever, and other conditions that increase oxygen needs Rationale: Tachypnea can occur in response to excitement, fear, respiratory distress, fever, and other conditions that increase oxygen needs.

Answer 173

D) Indicates respiratory distress and risk of hypoxemia if untreated Rationale: A sustained respiratory rate higher than normal for age is an important sign of respiratory distress, which can lead to hypoxemia if not treated.

Answer 174

A) Respiratory failure Rationale: An abnormally slow respiratory rate in a child may indicate respiratory failure, requiring immediate medical attention.

Answer 175

C) 6 years old Rationale: The normal respiratory rate range for a 6-year-old is 16–22 breaths per minute.

Answer 176

B) Chest movement, respiratory effort, deformities of the chest wall, and tactile fremitus Rationale: Palpation of the chest is used to evaluate chest movement, respiratory effort, deformities of the chest wall, and tactile fremitus, which are essential in assessing the overall respiratory function and detecting any abnormalities.

Answer 177

B) Bilateral symmetry of chest motion Rationale: When palpating the chest motion with respiration, it is important to confirm the bilateral symmetry of chest motion to ensure that both sides of the chest are moving equally, which indicates normal respiratory function.

Answer 178

B) Air escaping into the subcutaneous tissues, often indicating a serious injury to the upper or lower airway Rationale: The presence of crepitus, a crinkly sensation felt on the chest surface during palpation, indicates that air is escaping into the subcutaneous tissues. This often signals a serious injury to the upper or lower airway, requiring immediate medical attention.

Answer 179

C) Place your palms on each side of the child's chest, ask the child to repeat words, and compare the quality of vibrations side to side Rationale: To palpate tactile fremitus, place the palms of your hands on each side of the chest, ask the child to repeat a series of words or numbers, and move your hands systematically over the anterior and posterior chest, comparing the quality of vibrations side to side. Normal vibrations are usually palpated over the entire chest.

Answer 180

D) Air trapped in the lungs, as occurs with asthma Rationale: Decreased sensations of tactile fremitus indicate that air is trapped in the lungs, which can occur with conditions such as asthma. This finding is significant as it suggests an obstruction or limitation in airflow within the lung tissue.

Answer 181

C) Listen at the end of each cry when the infant takes a deep breath Rationale: If an infant is crying, listen at the end of each cry when the infant takes a deep breath to assess breath sounds, vocal resonance, and tactile fremitus.

Answer 182

D) Encourage them to blow a pinwheel or a piece of tissue off your hand Rationale: Encouraging toddlers and preschoolers to blow a pinwheel or a piece of tissue off your hand helps them take deep breaths, making it easier to auscultate subtle wheezes that occur at the end of expiration.

Answer 183

C) Vesicular breath sounds Rationale: Vesicular breath sounds are low-pitched, swishing, soft, and short expiratory sounds usually heard in older children but not in infants and young children.

Answer 184

C) Pneumothorax or airway obstruction Rationale: Absent or diminished breath sounds may indicate a pneumothorax or airway obstruction, both of which are serious conditions requiring immediate medical attention.

Answer 185

B) Have the child repeat a series of words, such as apple, banana, and cereal, and use the stethoscope to auscultate the chest, comparing the quality of sounds from side to side and over the entire chest Rationale: To evaluate vocal resonance, have the child repeat a series of words and use the stethoscope to auscultate the chest, comparing the quality of sounds from side to side and over the entire chest. Normally, voice sounds with muffled and indistinct words and syllables are heard throughout the chest.

Answer 186

A) Presence of a lung consolidation or abnormality Rationale: If voice sounds are not muffled and indistinct during auscultation, it may indicate the presence of lung consolidation or an abnormality, such as pneumonia or pleural effusion, which can enhance the transmission of voice sounds through the lung tissue.

Answer 187

A) Air passing through watery secretions in the smaller airways Rationale: Fine crackles are high-pitched, discrete, noncontinuous sounds heard at the end of inspiration and are caused by air passing through watery secretions in the smaller airways (alveoli and bronchioles).

Answer 188

C) Coarse crackles Rationale: Coarse crackles are loud, lower-pitched, more moist or bubbly sounds heard during inspiration and are caused by air passing through thicker secretions in the airway.

Answer 189

B) Air passing through mucus or fluids in a narrowed lower airway; described as a higher pitched, musical, squeaking, or hissing noise Rationale: Sibilant wheezing is caused by air passing through mucus or fluids in a narrowed lower airway (bronchioles) and is described as a higher pitched, musical, squeaking, or hissing noise.

Answer 190

D) Coarse, low-pitched sound like a snore; may clear with coughing Rationale: Rhonchi (sonorous wheezing) is a coarse, low-pitched sound like a snore heard during inspiration or expiration and may clear with coughing. It is caused by air passing through thick secretions that partially obstruct the larger bronchi and trachea.

Answer 191

B) Fine crackles are high-pitched, discrete sounds heard at the end of inspiration caused by air passing through watery secretions in smaller airways; coarse crackles are loud, lower-pitched, moist sounds during inspiration caused by air passing through thicker secretions in the airway Rationale: Fine crackles are high-pitched, discrete, noncontinuous sounds heard at the end of inspiration caused by air passing through watery secretions in the smaller airways, while coarse crackles are loud, lower-pitched, more moist or bubbly sounds heard during inspiration caused by air passing through thicker secretions in the airway.

Answer 192

C) Stridor; croup Rationale: Stridor is a high-pitched, piercing sound most often heard during inspiration without a stethoscope and is associated with croup, indicating a narrowing of the trachea and larynx.

Answer 193

D) A reflexive clearing of the airway associated with a respiratory infection Rationale: A cough is typically a reflexive clearing of the airway and is often associated with a respiratory infection, helping to remove mucus, irritants, or other substances from the respiratory tract.

Answer 194

D) Inflammation of the larynx Rationale: Hoarseness is commonly associated with inflammation of the larynx, which can occur due to infections, overuse of the voice, or other conditions that affect the vocal cords.

Answer 195

B) To assess the resonance of the lungs and size of underlying organs such as the heart; performed by an experienced examiner Rationale: Percussion of the chest is performed to assess the resonance of the lungs and the size of underlying organs, such as the heart. This assessment is typically conducted by an experienced examiner. For more detailed evaluation, radiographic examination is commonly used.

Answer 196

A) Near the midclavicular line at the fourth to sixth ribs Rationale: The nipples of prepubertal boys and girls are symmetrically located near the midclavicular line at the fourth to sixth ribs, providing a standard point of reference for inspection.

Answer 197

A) Association with congenital renal or cardiac anomalies Rationale: Supernumerary nipples, which are small, undeveloped nipples and areolae that may be mistaken for moles, can be associated with congenital renal or cardiac anomalies, warranting further evaluation.

Answer 198

C) To assess for possible underlying breast pathology Rationale: Palpating the nipples for discharge can help identify possible underlying breast pathology, which may require further investigation and management.

Answer 199

B) Around 14 years of age; disappears by full sexual maturity Rationale: Gynecomastia, the unilateral or bilateral enlargement of breasts, is most noticeable in boys around 14 years of age and typically disappears by full sexual maturity.

Answer 200

C) At the fourth intercostal space just medial to the left midclavicular line Rationale: In children under 7 years old, the apical impulse is located in the fourth intercostal space just medial to the left midclavicular line.

Answer 201

B) Using a concentric or vertical stripe pattern covering all areas of each breast, including the axilla, areola, and nipple Rationale: The correct technique for palpating the breasts involves using a concentric or vertical stripe pattern to cover all areas, including the axilla, areola, and nipple, to thoroughly detect any abnormal masses.

Answer 202

D) Femoral hernia Rationale: A small bulging noted over the femoral canal in girls may be associated with a femoral hernia, which requires further evaluation.

Answer 203

A) As a result of minor injuries on the legs Rationale: Small lymph nodes less than 1 cm in diameter are often present in the inguinal area because of minor injuries on the legs.

Answer 204

D) A local infection Rationale: Tenderness, heat, or inflammation in the palpated inguinal lymph nodes could be associated with a local infection, requiring further examination and possible intervention.

Answer 205

C) Auscultated apical heart rate Rationale: The brachial or radial pulse rate should be the same as the auscultated apical heart rate to ensure consistency in heart rate measurement.

Answer 206

B) Increased oxygen requirement and metabolic rate Rationale: Exercise, excitement, anxiety, and fever increase the child's metabolic rate, creating a higher oxygen requirement, which in turn increases the heart rate. This response is known as sinus tachycardia.

Answer 207

B) An irregular rhythm associated with respiration; detected by asking the child to take a breath and hold it while listening to the heart rate Rationale: Sinus arrhythmia in children is an irregular rhythm associated with respiration where the heart rate is faster on inspiration and slower on expiration. It can be detected by asking the child to take a breath and hold it while listening to the heart rate, which should become regular during inspiration and expiration.

Answer 208

C) 120 beats per minute Rationale: The average heart rate for a newborn is 120 beats per minute, within the range of 100 to 170 beats per minute.

Answer 209

C) 70-110 beats per minute Rationale: The normal heart rate range for children aged 6 to 10 years is 70 to 110 beats per minute, with an average of 90 beats per minute.

Answer 210

D) Ask the child to take a breath and hold it while listening to the heart rate Rationale: When any rhythm irregularity is detected, the nurse should ask the child to take a breath and hold it while listening to the heart rate. This helps to determine if the irregularity is sinus arrhythmia, which should become regular during inspiration and expiration.

Answer 211

A) Exercise, excitement, anxiety, and fever Rationale: Sinus tachycardia in children can be caused by exercise, excitement, anxiety, and fever, all of which increase the metabolic rate and oxygen requirement, leading to an increased heart rate.

Answer 212

C) To detect lower-pitched sounds Rationale: The bell of the stethoscope is used to detect lower-pitched sounds, which helps in identifying certain heart sounds and murmurs.

Answer 213

B) To detect differences in heart sounds caused by a change in the child's position or the position of the heart near the chest wall Rationale: Auscultating heart sounds in different positions helps detect differences caused by changes in the child's position or the position of the heart near the chest wall.

Answer 214

B) Heart defect or congestive heart failure Rationale:Muffled or indistinct heart sounds may indicate a heart defect or congestive heart failure, which requires further evaluation and intervention.

Answer 215

B) Left lateral recumbent position Rationale: If differences in heart sounds are detected with a position change, the child should be placed in the left lateral recumbent position and auscultated again to accurately assess heart sounds.

Answer 216

D) By detecting sounds produced by heart valves or blood turbulence, which are heard throughout the chest Rationale: Auscultation in thin infants and children can help diagnose heart conditions by detecting sounds produced by heart valves or blood turbulence, which are more easily heard throughout the chest due to less tissue obstruction.

Answer 217

A) The pulmonic valve closing a fraction of a second later than the aortic valve during deep inspiration Rationale: Physiologic splitting of S2 occurs when the child takes a deep breath, causing more blood to return to the right ventricle than the left, resulting in the pulmonic valve closing a fraction of a second later than the aortic valve.

Answer 218

C) S3 is louder in the mitral area than in the pulmonic area and occurs in diastole, just after S2 Rationale: A third heart sound (S3) can be distinguished from a split S2 because S3 is louder in the mitral area than in the pulmonic area and occurs in diastole, just after S2.

Answer 219

D) Tricuspid area Rationale: The tricuspid area is one of the sites where the apex of the heart is best heard during auscultation.

Answer 220

B) Place the child in the left lateral recumbent position and auscultate again Rationale: If differences in heart sounds are detected with a position change, the child should be placed in the left lateral recumbent position and auscultated again to ensure accurate assessment.

Answer 221

C) Blood rushing through the mitral valve and splashing into the left ventricle Rationale: The third heart sound (S3) is caused by blood rushing through the mitral valve and splashing into the left ventricle. It is heard in diastole, just after S2, and is louder in the mitral area than in the pulmonic area.

Answer 222

A) Blood passing through a defective valve, great vessel, or other heart structure Rationale: Murmurs, or abnormal heart sounds, are often produced by blood passing through a defective valve, great vessel, or other heart structure. Some murmurs are benign or innocent, while others may indicate a congenital heart defect.

Answer 223

all of the above

Answer 224

B) The murmur may be influenced by physiological changes such as blood flow dynamics Rationale: If the murmur's characteristics change when the child changes position, it suggests that the murmur may be influenced by physiological changes such as blood flow dynamics, requiring further investigation to understand its significance.

Answer 225

C) Brachial artery in the arms and the popliteal or femoral artery in the legs Rationale: Due to the difficulty of detecting distal pulses in infants, it is recommended to use the brachial artery in the arms and the popliteal or femoral artery in the legs for pulse evaluation.

Answer 226

C) Radial and distal tibial pulses Rationale: In older children, the radial and distal tibial pulses are normally easy to palpate, making them suitable for routine pulse evaluation.

Answer 227

B) 3 to 5 minutes Rationale: To obtain an accurate blood pressure reading, it is recommended that the child be seated and quiet for 3 to 5 minutes before the assessment.

Answer 228

D) This arm was used for the development of blood pressure standards Rationale: The right arm is preferred for blood pressure measurement in children because it was used for the development of blood pressure standards, ensuring consistency and comparability.

Answer 229

A) Higher blood pressure reading in the arm than in the leg Rationale: If the blood pressure reading in the leg is lower than that in the arm, it may indicate coarctation of the aorta, as normally the leg's blood pressure should be 10 to 20 mmHg higher than the arm's reading.

Answer 230

C) Poor perfusion of the tissues Rationale: A capillary refill time of greater than 2 seconds indicates poor perfusion of the tissues, suggesting potential cardiovascular compromise or circulatory issues.

Answer 231

D) Congenital heart defect Rationale: Cyanosis, a bluish discoloration of the skin due to lack of oxygen, is most commonly associated with a congenital heart defect in children, indicating inadequate oxygenation of blood.

Answer 232

C) Lying supine across both the parent’s and the examiner’s laps Rationale: Infants and toddlers often feel more secure when lying supine across both the parent’s and the examiner’s laps during an abdominal assessment.

Answer 233

B) By using suggestive words to guide the child in relaxing their abdomen Rationale: The examiner can help a child relax their abdomen by using suggestive words to guide them, such as asking how soft their tummy can get when the examiner’s hand feels it, and encouraging the child to breathe out and relax.

Answer 234

B) Use a firm touch and avoid pretending to tickle the child Rationale: To effectively palpate a ticklish child’s abdomen, the examiner should use a firm touch and avoid pretending to tickle the child, which helps to reduce the child’s ticklish response and allows for a more accurate examination.

Answer 235

A) Dehydration Rationale: A scaphoid or sunken abdomen is abnormal and may indicate dehydration in a child, requiring further evaluation and management.

Answer 236

C) Infection or granuloma Rationale: Continued drainage from the umbilicus after a newborn's umbilical stump falls off may indicate an infection or a granuloma, both of which need medical attention.

Answer 237

B) To monitor changes over time and determine if the separation becomes less prominent as muscle strength develops Rationale: Measuring the width of abdominal wall separation in infants and toddlers helps to monitor changes over time and determine if the separation becomes less prominent as the child's abdominal muscle strength develops. Persistent separation may indicate congenital muscle weakness.

Answer 238

D) The abdomen rises simultaneously with the chest during inspiration and falls with expiration Rationale: Infants and children up to 6 years of age breathe with the diaphragm, causing the abdomen to rise simultaneously with the chest during inspiration and fall with expiration.

Answer 239

C) Intestinal obstruction Rationale: The presence of peristaltic waves, which are visible rhythmic contractions of the intestinal wall smooth muscle, generally indicates an intestinal obstruction, such as pyloric stenosis.

Answer 240

C) Auscultate for at least 5 minutes in each quadrant Rationale: Before determining that bowel sounds are absent, it is important to auscultate for at least 5 minutes in each quadrant to ensure a thorough assessment.

Answer 241

D) A narrowed or defective artery Rationale: A vascular murmur heard during abdominal auscultation may indicate a narrowed or defective artery, which requires further investigation.

Answer 242

A) Presence of an intestinal obstruction or air swallowing Rationale: Tympany found over the stomach or intestines during abdominal percussion indicates the presence of an intestinal obstruction or air swallowing, which can affect normal digestion and require further evaluation.

Answer 243

A) B) To evaluate the tenseness of the abdomen, the liver, the presence of any tenderness or masses, and any defects in the abdominal wall Rationale: Light palpation is used to evaluate the tenseness of the abdomen (how soft or hard it is), the liver, the presence of any tenderness or masses, and any defects in the abdominal wall.

Answer 244

C) Supine with knees flexed Rationale: To begin palpation of the abdomen, position the child supine with knees flexed. This position helps relax the abdominal wall, making it easier to palpate organs and detect any masses.

Answer 245

B) The diameter of the muscular ring Rationale: If an umbilical hernia is present, you should measure the diameter of the muscular ring rather than the protrusion. This helps in monitoring the hernia as the muscle ring normally becomes smaller and closes by 4 years of age.

Answer 246

C) Liver enlargement possibly due to congestive heart failure or hepatic disease Rationale: If the liver edge is palpated more than 3 cm below the right costal margin in infants and toddlers, it may indicate liver enlargement, possibly due to congestive heart failure or hepatic disease.

Answer 247

A) Ask the child to take regular deep breaths Rationale: The abdominal muscles are most relaxed when the child takes a deep breath, so asking the child to take regular deep breaths during deep palpation helps in accurately assessing the abdominal organs.

Answer 248

C) Spleen enlargement, possibly due to an underlying condition Rationale: If the spleen tip is easily palpated below the left costal margin, it indicates spleen enlargement, which could be due to conditions such as congestive heart failure or hepatic disease and requires further evaluation.

Answer 249

B) Shorter extremity Rationale: Extra skinfolds and a larger circumference in one extremity may indicate a shorter extremity, which requires further assessment.

Answer 250

D) An active seizure or cerebral palsy Rationale: Rigid muscles, or hypertonia, may be associated with an active seizure or cerebral palsy, indicating a need for further evaluation and management.

Answer 251

A) Recent fracture or a bone tumor Rationale: A mass over a long bone may indicate a recent fracture or a bone tumor, necessitating further investigation.

Answer 252

B) Swelling, masses, heat, or tenderness Rationale: Swelling, masses, heat, and tenderness should be absent when palpating a child's joints and surrounding muscles, as these findings could indicate injury or chronic joint inflammation.

Answer 253

B) By engaging the child in games that require squeezing, pushing, and pulling Rationale: The examiner can assess the strength of specific muscles in the extremities by engaging the child in games that involve squeezing the examiner’s fingers, pushing and pulling against the examiner’s hands, and resisting extension of flexed joints.

Answer 254

C) Nerve injury Rationale: Unilateral muscle weakness may be associated with a nerve injury, requiring further assessment to determine the underlying cause.

Answer 255

A) The child uses their arms to push their body upright; indicates generalized muscle weakness, possibly due to muscular dystrophy Rationale: A positive Gowers sign occurs when a child uses their arms to push their body upright, which may indicate generalized muscle weakness, often associated with conditions like muscular dystrophy.

Answer 256

B) Straight with a minimal angle at the elbows where the bones articulate Rationale: The normal alignment of a child's arms is straight, with a minimal angle at the elbows where the bones articulate, indicating proper bone structure and alignment.

Answer 257

A) Extra finger digits and webbed fingers; both are abnormal Rationale: Polydactyly refers to extra finger digits, and syndactyly refers to webbed fingers. Both conditions are considered abnormal and may require further medical evaluation.

Answer 258

B) Chronic respiratory or cardiac conditions Rationale: Clubbing, which is the widening of the nail bed with an increased angle between the proximal nail fold and nail, is abnormal and is associated with chronic respiratory or cardiac conditions.

Answer 259

B) Hip dislocation or difference in leg length Rationale: Unequal skinfolds on the upper legs of a newborn or young infant may indicate hip dislocation or a difference in leg length, requiring further assessment using the Ortolani and Barlow maneuvers.

Answer 260

B) Weak hip abductor muscles on the weight-bearing side Rationale: A positive Trendelenburg sign, where the iliac crest on the lifted leg appears lower, indicates weak hip abductor muscles on the weight-bearing side, necessitating further evaluation and possibly intervention.

Answer 261

D) Straight at the knees and ankles Rationale: After a child is 4 years of age, the alignment of the long bones is expected to be straight at the knees and ankles, indicating normal skeletal development.

Answer 262

C) No more than 1.5 inches (3.5 cm) between the knees Rationale: To evaluate the alignment in a toddler with bowlegs, the distance between the knees should be no more than 1.5 inches (3.5 cm) when the child’s ankles are together, which is considered within normal limits.

Answer 263

B) Twisting of the tibia; causes toes to turn inward Rationale: Tibial torsion is the twisting of the tibia caused by positioning in utero, resulting in the infant’s toes turning inward.

Answer 264

A) Bowlegs (genu varum) and knock-knees (genu valgum) Rationale: Toddlers typically go through a sequence of bowlegs (genu varum) and knock-knees (genu valgum) before their legs assume a straight alignment.

Answer 265

B) Flat feet appearance; due to a fat pad over the arch Rationale: In children up to 3 years of age, the arch appears flat due to a fat pad over the arch, which is a normal developmental stage.

Answer 266

B. The infant's use of gestures to communicate needs. Rationale: At 6 months old, infants are typically non-verbal and communicate primarily through non-verbal cues such as gestures, facial expressions, and sounds. Following verbal commands and solving puzzles are skills that develop later, and recounting events is beyond the capabilities of an infant at this stage.

Answer 267

C. The neurologic examination should be tailored to match the child’s developmental stage. Rationale: The assessment of cognitive function must be adapted to the child’s age and developmental stage. Infants and young children communicate and demonstrate cognitive function through different behaviors compared to older children, requiring age-appropriate examination techniques. Facial expressions and gestures remain important indicators of cognitive function across different ages, especially in younger children who cannot communicate verbally.

Answer 268

D. The toddler frequently looks at the parent and seeks their comfort. Rationale: Infants and toddlers demonstrate a healthy level of alertness by showing curiosity about their environment while also seeking security from their parents through frequent eye contact or physical closeness.

Answer 269

A. The child exhibits excessive activity and has a very short attention span. Rationale: Excessive activity and an unusually short attention span are behaviors associated with attention deficit hyperactivity disorder (ADHD) in children.

Answer 270

C. The child may be experiencing a serious illness. Rationale: A lack of interest in assessment or treatment procedures can be an indicator of a serious illness in children. It is important for the nurse to consider this possibility and conduct further evaluation to determine the underlying cause of the behavior. These questions are designed to test a nurse's understanding of behavioral indicators of health and potential issues in pediatric patients.

Answer 271

D. The child follows simple directions like "Show me your mouth." Rationale: Toddlers around the age of 2 are expected to follow simple directions, such as "Show me your mouth." This ability indicates normal speech and language development for their age. Reciting the alphabet, using complete sentences, and reading a storybook are skills that develop at later stages.

Answer 272

A. The child's speech is not easily understood by most people. Rationale: By 3 years of age, a child’s speech should be easily understood by most people. If a 3-year-old's speech is not clear, it may indicate a delay in language development, which could be associated with cognitive disability or hearing loss. These questions aim to assess a nurse's ability to recognize normal and delayed speech and language development in children, which are crucial indicators of cognitive functioning.

Answer 273

B. 4-6 months Rationale: Infants typically begin to babble speechlike sounds including "p," "b," and "m" at around 4-6 months of age, marking an important milestone in language development.

Answer 274

C. Has 1-2 words like "mama," "dada," and "bye-bye" Rationale: By 12 months of age, a child typically has 1-2 words such as "mama," "dada," and "bye-bye," indicating early language development.

Answer 275

B. 2-3 years Rationale: Children typically begin to form two- to three-word sentences to ask for or talk about things and have a large vocabulary between the ages of 2-3 years.

Answer 276

C. 3-4 years Rationale: By 3-4 years of age, a child’s speech is typically understood by most people, not just immediate family members, indicating normal language development.

Answer 277

C. "l," "s," and "r" Rationale: By the age of 4, children can say most sounds correctly, but may still struggle with more complex sounds such as "l," "s," "r," "v," "z," "ch," "sh," and "th."

Answer 278

C. Forming two- to three-word sentences with a large vocabulary Rationale: By 5 years of age, a child has typically surpassed the milestone of forming two- to three-word sentences with a large vocabulary, now using more complex sentences and storytelling. These questions should help in evaluating understanding of language development milestones in children.

Answer 279

A. Asking the child to repeat a series of four words or numbers. Rationale: Immediate memory in a 5-year-old child can be effectively assessed by asking them to repeat a series of four words or numbers, which aligns with their developmental stage.

Answer 280

D. Asking the child to remember and recall a special name or object after 5 to 10 minutes. Rationale: Recent memory in a 4-year-old child can be evaluated by asking them to remember and recall a special name or object after a short period of time, typically 5 to 10 minutes, during the examination.

Answer 281

B. Reciting their address or birth date. Rationale: Remote memory in a 6-year-old child can be assessed by asking them to recite personal information such as their address or birth date, which they should be able to recall without difficulty by this age.

Answer 282

C. The child may have a neurologic condition such as a brain injury, seizure, infection, or brain tumor. Rationale: A lowered level of consciousness in a child can be associated with various neurologic conditions, including brain injury, seizure, infection, or brain tumor. This requires further medical evaluation to determine the underlying cause.

Answer 283

B. Watching the child stack blocks into a tower. Rationale: Observing a child stack blocks into a tower is an effective way to assess cerebellar function, as this activity requires coordination, balance, and fine motor skills. It provides insight into the child’s ability to perform tasks that involve precision and stability, which are key indicators of cerebellar health.

Answer 284

B. Standing on one foot and hopping. Rationale: Observing a child’s ability to stand on one foot and hop provides valuable information about their balance and motor skills, which are key indicators of cerebellar function and overall coordination.

Answer 285

A. Cerebellar dysfunction or an inner ear disturbance. Rationale: Poor balance in a child may indicate issues related to cerebellar dysfunction or an inner ear disturbance, both of which can affect the child's ability to maintain stability during physical activities.

Answer 286

B. 12 months Rationale: By the age of 12 months, children are typically expected to stand without support briefly, indicating normal balance development for this stage.

Answer 287

B. 15 months Rationale: Children typically achieve the milestone of walking alone well by the age of 15 months, showing development in their balance and motor skills.

Answer 288

C. Walks backwards Rationale: By the age of 2 years, children are expected to be able to walk backwards, demonstrating an important balance milestone.

Answer 289

D. Balances on 1 foot momentarily Rationale: By the age of 3 years, children should be able to balance on 1 foot momentarily, indicating normal development of balance and coordination.

Answer 290

C. Hops on 1 foot Rationale: At the age of 4 years, children are typically expected to be able to hop on 1 foot, demonstrating advanced balance and motor skills.

Answer 291

D. Finger-to-nose test Rationale: After the age of 6, the finger-to-nose test, along with other adult coordination tests (finger-to-finger, heel-to-shin, and alternating motion), is appropriate for assessing coordination in children.

Answer 292

B. Poor coordination, potentially associated with delayed development or a cerebellar lesion Rationale: Jerky movements or inaccurate pointing (past pointing) can indicate poor coordination, which may be associated with delayed development or a cerebellar lesion. This requires further evaluation to determine the underlying cause.

Answer 293

A. 4 months Rationale: By the age of 4 months, infants are typically expected to reach for a toy with one hand, indicating the development of fine motor skills.

Answer 294

B. Transfers objects between hands, brings objects to mouth Rationale: By the age of 6 months, infants are expected to transfer objects between hands and bring objects to their mouth, showcasing important fine motor development.

Answer 295

C. 9 months Rationale: By the age of 9 months, infants typically develop the thumb-finger grasp, allowing them to pick up small objects.

Answer 296

B. Bangs items together, releases toy without help Rationale: At around 12 months of age, children are expected to bang items together and release toys without help, indicating fine motor development.

Answer 297

D. 24 months Rationale: By the age of 24 months (2 years), children are typically able to build a tower of four or more blocks, demonstrating their fine motor skill development. These questions aim to test the nurse's understanding of fine motor milestones in children and the expected ages at which these skills are attained.

Answer 298

C. Scissoring of the thighs with each step Rationale: Scissoring, where the thighs cross forward over each other with each step, can be associated with cerebral palsy or other spastic conditions and would be a concerning observation in a walking toddler.

Answer 299

B. Cerebellar ataxia Rationale: Staggering or falling during walking can indicate cerebellar ataxia, a condition that affects coordination and balance, and requires further evaluation to determine the cause.

Answer 300

A. Wide-based gait with limited balance Rationale: Toddlers who are just beginning to walk typically exhibit a wide-based gait with limited balance, which is normal and expected as they gain more balance and coordination over time.

Answer 301

A. I Olfactory Rationale: The olfactory nerve (cranial nerve I) is not routinely tested in infants but can be assessed in children by having them identify familiar odors one naris at a time.

Answer 302

B. A quick blink reflex and dorsal head flexion Rationale: Shining a bright light in an infant's eyes should elicit a quick blink reflex and dorsal head flexion, indicating light perception.

Answer 303

C. III Oculomotor, IV Trochlear, and VI Abducens Rationale: The oculomotor (III), trochlear (IV), and abducens (VI) nerves are assessed together by moving an object through the six cardinal points of gaze and observing the child’s ability to track the object.

Answer 304

B. Eyelids do not droop and pupils are equal size and briskly respond to light Rationale: Normal findings include no drooping of the eyelids and pupils that are equal in size and briskly respond to light.

Answer 305

B. Stimulating the rooting and sucking reflex Rationale: The trigeminal nerve in infants is assessed by stimulating the rooting and sucking reflex, where the infant turns the head toward stimulation at the side of the mouth and demonstrates good sucking strength and pattern.

Answer 306

A. Symmetric facial expressions when crying, smiling, or frowning Rationale: Normal facial nerve function is indicated by symmetric facial expressions during various emotional states such as crying, smiling, and frowning.

Answer 307

C. Producing a loud sound near the head Rationale: The acoustic nerve in infants is assessed by producing a loud sound near the head and observing the infant's response, such as blinking, moving the head toward the sound, or freezing position.

Answer 308

B. Observing swallowing during feeding Rationale: In infants, the glossopharyngeal and vagus nerves are assessed by observing the infant’s swallowing pattern during feeding, ensuring it is good and coordinated.

Answer 309

D. Raising the shoulders and turning the head side to side against resistance Rationale: The spinal accessory nerve in children is assessed by asking the child to raise their shoulders and turn their head side to side against resistance, indicating good strength in the neck and shoulders.

Answer 310

A. Asking the child to stick out the tongue and listening to speech Rationale: The hypoglossal nerve is assessed by asking the child to stick out their tongue and listening to their speech. Normal findings include the tongue being midline with no tremors and clearly articulated words.

Answer 311

C. Testing vision and visual fields Rationale: In a cooperative child, the optic nerve can be assessed by testing vision and visual fields, ensuring visual acuity is appropriate for their age.

Answer 312

D. V Trigeminal Rationale: The trigeminal nerve in children is assessed by touching the forehead and cheeks with a cotton ball while the child’s eyes are closed, and the child should be able to point to the location touched.

Answer 313

C. Facial expressions when crying, smiling, frowning Rationale: The facial nerve is assessed by observing the child’s facial expressions during various emotional states to ensure facial features stay symmetric bilaterally.

Answer 314

B. Whispering words and asking for them to be repeated Rationale: The acoustic nerve is assessed by whispering words and asking the child to repeat them correctly, ensuring hearing and comprehension are intact.

Answer 315

C. Gagging with stimulation Rationale: A normal response when eliciting the gag reflex is gagging with stimulation, indicating proper function of the glossopharyngeal (IX) and vagus (X) nerves.

Answer 316

C. Withdrawal response to painful procedures Rationale: A withdrawal response to painful procedures indicates normal sensory function in an infant, showing that the infant can perceive and respond to pain.

Answer 317

D. By stroking the skin on the lower leg or arm with a cotton ball or finger while the child's eyes are closed Rationale: Superficial tactile sensation in a cooperative child over 2 years of age is tested by stroking the skin on the lower leg or arm with a cotton ball or finger while the child’s eyes are closed. The child should be able to point to the location touched.

Answer 318

B. Alternating the sharp and dull ends of a broken tongue blade or paper clip and asking the child to distinguish between them Rationale: Superficial pain sensation in children over 4 years of age is tested by alternating the sharp and dull ends of a broken tongue blade or paper clip and asking the child to distinguish between the sensations each time.

Answer 319

B. Sensory loss, potentially indicating a brain or spinal cord lesion Rationale: An inability to identify superficial touch and pain sensations may indicate sensory loss, which could be associated with a brain or spinal cord lesion. It is important to identify the extent of sensory loss for further evaluation.

Answer 320

D. Medication administration schedule Rationale: Elements of a health history include the chief concern, details about the present illness or injury, past health history, current health status, psychosocial and developmental data, family history, and review of systems. Medication administration schedule is not typically part of the health history.

Answer 321

B. Introducing yourself and explaining the purpose of the interview Rationale: Introducing yourself and explaining the purpose of the interview, along with other strategies such as providing privacy and confidentiality, using open-ended questions, and asking one question at a time, helps improve the quality of health information collected.

Answer 322

A. Allowing the child to stay on the parent’s lap Rationale: Allowing the child to stay on the parent's lap, providing an opportunity for the child to hold and inspect any equipment before it is used, and making a game out of tests for muscle strength, coordination, and developmental assessment are strategies that may help improve cooperation.

Answer 323

B. Feet-to-head Rationale: For infants and toddlers, procedures should be performed in a feet-to-head sequence to postpone the ear and throat examination that cause anxiety until the end. This sequence helps minimize distress during the examination.

Answer 324

C. Measuring the head circumference Rationale: Special assessment techniques for infants and toddlers include measuring the head circumference, palpating the fontanelles, using toys to assess vision and hearing, and keeping the child on the parent's lap.

Answer 325

B. Using easily recognized names or words Rationale: Examination modifications for preschoolers include using easily recognized names or words to assess hearing and memory, using play and games to assess muscle strength and coordination, and asking the child to show the teeth to begin assessment of the mouth.

Answer 326

C. Body mass index (BMI) Rationale: The body mass index (BMI) is used to determine if the child's weight is appropriate for their height. Accurate measurements of length, height, weight, and head circumference are also important for evaluating the growth pattern of a child.

Answer 327

A. Altered level of consciousness Rationale: Examples of unexpected physical examination findings that require urgent nursing intervention include altered level of consciousness, bradycardia, tachypnea, pain, signs of dehydration, stridor, retractions, and cyanosis.