Week 5/6

Question 1

Which assessment finding in an 18-month-old would indicate the need for further evaluation?

1. Scribbles with crayon or pencil
2. Has a vocabulary of four words
3. Has a positive Moro reflex
4. Has 2+ deep tendon reflexes

Answer 1

A. Vocabulary of 4 words.

Question 2

The nurse is preparing to assess a child. The physical examination should begin when the nurse:

1. Has recorded the child’s vital signs.
2. Has finished obtaining information related to daily routines.
3. First sees the child.
4. Has completed the health history interview with the parents.

Answer 2

3. First sees the child.

Question 3

Which statement by the mother indicates understanding of the nurse’s teaching related to a newborn?

1. I should expect my baby to breathe slower than I do.
2. My baby’s skin will be yellow for about a month.
3. The soft spot on the top of my baby’s head will close when he is 4 weeks old.
4. I should use a blanket to swaddle my newborn when he is sleeping.

Answer 3

4. I should use a blanket to swaddle my newborn when he is sleeping.

Question 4

Put the following nursing assessments of a toddler in the best order for the nurse to proceed (from first assessment to last assessment).
• Auscultation of chest
• Examination of eyes, ears, and throat
• Palpation of abdomen
• General appearance

Answer 4

1. General appearance 2. Auscultation
2. Palpation of abdomen
3. Exam eyes, ears and throat.

Question 5

The nurse wants to do a quick evaluation of a one-month-old infant’s hearing. Which assessment will provide the best information?

Answer 5

Using a noisemaker in the infant’s presence to evaluate the child’s response

Question 6

Facilitating examination of infants <6 mths:

Answer 6

• praise parental presence and response
• Promote physical comfort and relaxation
• Distract infant with colourful toys
• Use warm, gentle hands and stethoscope
• Ausculate when quiet or sleeping
• Do procedures that provoke crying at end of exam

Question 7

Facilitating examination of infants >6 mths:

Answer 7

• keep infant as close to parent as possible to avoid separation/stranger anxiety
• Promote comfort - warm room, hands

Question 8

While assessing a seven-year-old girl, the nurse notices a regular-irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. What is the most appropriate action for the nurse to take next? (True or False)
A. Record the finding as normal.
B. Notify the physician
C. Schedule an EKG.
D. Ask the mother if a murmur has been detected before.

Answer 8

A. Record the finding as normal.

Rationale: This is sinus arrhythmia and is a normal finding in children but not in adults

Question 9

Normal heart rates for Infants and Children

Answer 9

Newborn 100-160
1 wk to 3 mths 100-220
3 mths to 2 yrs 80-150
2 yrs to 10 yrs 70-110
10 yrs to adult 55-90

Question 10

Norm Temps for 3 mth, 5 yrs, 13 yrs

Answer 10

3mths: 37.5, 5 yrs: 37.0, 13 yrs: 36.6

Question 11

Characteristics of communicative development in young children

Answer 11

Perlocutionary Stage (0 to 8-9 mths)
* Child is reflexive to stimuli
* Child shows increasing purpose in action.
Emerging Illocutionary Stage (8-9 to 12-15 mths)
* Child communicates intentionally with signals and gestures
Conventional Illocutionary-Emerging Locutionary Stage (12-15 to 18-24 mths)
* Child communicates intentionally with gestures, vocalisations and verbalisations.