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
Which questions will the nurse include in the health history for an infant when assessing the birth history? Select all that apply.
- “When did you first receive prenatal care when you learned you were pregnant?”
- “Where was your baby born?”
- “Was your baby born vaginally or by cesarean birth?”
- “Is your baby experiencing vomiting after bottle feedings?”
- “Does your baby take any medications on a regular basis?”
1,2,3
Which assessment strategies are appropriate when assessing a family of Asian descent, who speak fluent English, during a scheduled health maintenance appointment for a toddler-age child? Select all that apply.
- Using open-ended questions
- Phrasing questions in a neutral manner
- Avoiding prolonged eye contact
- Asking all questions directly to the interpreter
- Asking several questions for time management purposes
1,2,3
Which actions by the nurse are appropriate to enhance cooperation when assessing a 10-month-old infant? Select all that apply.
- Placing the infant on the examination table
- Using toys to distract the infant
- Touching the infant’s feet before moving on to the trunk
- Keeping the infant’s clothing on during the process
- Observing the infant’s interaction with the mother while she is holding the baby
2,3,5
Which statements are true in regard to the physical assessment the nurse conducts for an infant and a toddler? Select all that apply.
- An infant client will have all clothing removed during the weight assessment.
- A toddler client’s assessment will include a length assessment instead of a height assessment.
- An infant client will have a blood pressure assessment at each visit.
- It is inappropriate to ask the toddler-age client if he or she can perform certain tasks.
- It is appropriate to allow the toddler-age client to play with equipment prior to use.
1,4
Which techniques would the nurse use when assessing a preschool-age child? Select all that apply.
- Asking the child to sit on the examination table
- Having the child undress for the examination leaving on the undergarments.
- Asking the child when he or she would like to have head, eyes, and ears assessed
- Asking direct questions to the child
- Having the parent of the child leave the room for the duration of the exam
1,2,3,4
