Question 1

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?

Accepted Answer

This pattern of heart rate variability is known as sinus arrhythmia, which is a normal finding, especially in children. It reflects the heart's ability to adjust its rate with breathing, increasing during inspiration and decreasing during expiration.

Question 2

A nurse caring for a nine-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation. Based on these physical findings, the nurse would be most concerned with assessing:

Accepted Answer

The slow disappearance of the indentation after pressing on the ankle bone suggests edema, which can be caused by a variety of conditions, including fluid overload or kidney problems affecting urine output. Therefore, assessing urine output would be the most relevant concern in this situation. Skin integrity, level of consciousness, and range of motion and ankle mobility may also be important to assess, but they are not the most concerning based on the given physical findings.

Question 3

A nurse working in the newborn nursery notes that an infant is having frequent episodes of apnea lasting 10 to15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate?

Accepted Answer

It is common for newborns to have short episodes of apnea, lasting up to 15 seconds, without changes in color or heart rate. The appropriate intervention in this case would be to continue to observe the infant and call the physician only if the apnea lasts longer than 20 seconds. Suctioning the infant's mouth and nares or turning the infant on its right side are not effective interventions for this situation. Calling the physician immediately would be unnecessary and potentially alarming.

Question 4

A very concerned 14-year-old boy presents to the clinic because of an enlargement of his left breast. Except for the breast enlargement, the client's history and physical are normal. The most appropriate intervention for the nurse to implement next would be to inform the child that:

Accepted Answer

Breast enlargement in adolescent males is a common finding and is usually caused by a temporary increase in estrogen levels as a result of hormonal changes during puberty. This condition, called gynecomastia, usually regresses on its own by the time of full sexual maturity. Therefore, assuring the child that this is a normal finding and that no further intervention or treatment is necessary is the most appropriate intervention for the nurse to implement next.

Question 5

While evaluating development of children, the nurse notes that the development of secondary sexual characteristics follows a typical pattern. Place the appearance of secondary sexual characteristics in the female in order of appearance from earliest to latest. Standard Text: Click and drag the options below to move them up or down.

Accepted Answer

Breast budding typically appears first, followed by the growth of pubic hair. The appearance of secondary sexual characteristics progresses with breast development reaching Tanner stage 5, where the areola is strongly pigmented, and finally menarche occurs, which marks the onset of fertility.

Question 6

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. Which finding would strongly suggest this disorder?

Accepted Answer

Asymmetric thigh and gluteal folds are one of the hallmark signs of developmental dysplasia of the hip. Other signs may include limited hip abduction, a positive Ortolani maneuver, and leg length discrepancy. The other answer choices are not related to developmental dysplasia of the hip.

Question 7

While assessing newborns, the nurse should differentiate normal findings from findings which require further evaluation and intervention. Which would be normal newborn findings? Standard Text: Select all that apply.

Accepted Answer

- A) Swelling over the occiput that crosses suture lines is a normal finding known as caput succedaneum, which is common in newborns due to the pressure during birth.- B) Tiny white papules located primarily on the nose and chin are known as milia and are common in newborns due to developing sebaceous glands.- C) Tiny red macules and pustules that come and go, primarily on the trunk and extremities, are known as erythema toxicum and are a common benign rash in newborns.

Question 8

The nurse is taking a health history from the family of a three-year-old child. Which statement or by the nurse would be most likely to establish rapport and elicit an accurate response from the family?

Accepted Answer

A) "Tell me about the concerns that brought you to the clinic today." is an open-ended question that invites the family to share their concerns in their own words, establishing rapport and encouraging a more detailed and accurate response.

Question 9

The nurse is caring for an infant diagnosed with "failure to thrive." The nurse observes the physician taking blood pressures in all four extremities and recognizes that the physician suspects which congenital cardiac defect?

Accepted Answer

Coarctation of the aorta can cause decreased blood flow to the lower body, possibly leading to "failure to thrive." Checking blood pressures in all four extremities can help diagnose coarctation of the aorta as there may be a significant difference in blood pressure readings between the upper and lower extremities. Tetralogy of Fallot, ventricular septal defect, and pulmonary atresia are congenital cardiac defects that do not typically present with decreased blood flow to the lower body as a symptom.

Question 10

The nurse is assessing a newborn while the new parents watch. The nurse uses an ophthalmoscope to examine the back of the eye (the retina) and notes a positive red reflex. The nurse would explain to the parents that the red reflex indicates:

Accepted Answer

A positive red reflex indicates the absence of congenital cataracts, which is a common cause of vision impairment in infants. Intraocular hemorrhage, optic nerve trauma, and amblyopia would not be indicated by a positive red reflex.

Question 11

A seven-year-old presents to the clinic with an exacerbation of asthma symptoms. On physical exam, the nurse would expect which of the following findings? Standard Text: Select all that apply.

Accepted Answer

In asthma exacerbation, airway obstruction leads to decreased transmission of sound and vibrations. Therefore, decreased vocal resonance and decreased tactile fremitus are expected. Wheezing is a hallmark sign of airway constriction seen in asthma. Increased tactile fremitus and bronchophony are more indicative of conditions where lung tissue is denser, such as pneumonia, not asthma.

Question 12

While inspecting a five-year-old child's ears with an otoscope, the nurse notes that the right membrane is red and there is an absence of light reflex. In view of these findings, which vital sign parameter would most concern the nurse?

Accepted Answer

A red eardrum (tympanic membrane) and absence of light reflex can indicate an ear infection (otitis media), which can lead to fever. Therefore, an elevated temperature would be the vital sign of most concern.

Question 13

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

Accepted Answer

Using a noisemaker in the infant's presence to evaluate the child's response is the best method for evaluating hearing in a one-month-old infant. This is typically done by using an automated auditory brainstem response (AABR) test, which uses a small earphone in the infant's ear to present sounds and measure the response in the baby's brain. This test is quick and non-invasive, and is recommended as a screening tool for infants within the first month of life.

Question 14

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would the nurse suspect as having an ongoing disease process?

Accepted Answer

Yellowing of the sclerae, or jaundice, is often a sign of liver dysfunction. In a 10-month-old infant, this could be due to various causes such as biliary atresia, hepatitis, or other liver diseases. The gastrointestinal system plays a key role in the function of the liver, as the liver receives nutrient-rich blood from the gut via the portal vein. Thus, the nurse would suspect the gastrointestinal system as having an ongoing disease process in this case.

Question 15

Put the following nursing assessments of a toddler in the best order for the nurse to proceed (from first assessment to last assessment). Standard Text: Click and drag the options below to move them up or down.

Accepted Answer

The general appearance of the toddler should be assessed first as this can provide initial clues about the child's overall health status. Examination of eyes, ears, and throat can follow as these are important areas to assess for possible infections or inflammation. Next, auscultation of chest should be performed to assess the child's respiratory status. Lastly, palpation of abdomen can be done to assess for any tenderness or distention.

Question 16

To accurately access blood pressure on a child, the nurse would select a cuff:

Accepted Answer

The best choice for assessing blood pressure in a child is to select a cuff that covers 2/3 of the upper arm with a bladder that wraps around at least 80% of the circumference of the arm. This ensures accuracy in the blood pressure reading for the child. Option A is partially correct as the cuff label "child" would be appropriate but it does not provide information on the cuff size or bladder circumference. Option C is incorrect as availability of cuffs should not be a factor in selecting the appropriate cuff size for blood pressure assessment. Option D is incorrect as the cuff should cover at least 2/3 of the upper arm not just 50%.

Question 17

The nurse is completing a physical examination of a four-year-old child. The best position in which to place the child for assessment of the genitalia would be:

Accepted Answer

The frog-leg position is the best position for assessment of the genitalia in a four-year-old child. The child is lying on their back with their knees bent and feet touching each other, allowing for better visualization and access to the genital area. The other positions listed would not provide optimal access and visualization of the genitalia.

Question 18

The nurse is assessing a new admission to the newborn nursery. Which physical findings suggest the infant was preterm? Standard Text: Select all that apply.

Accepted Answer

Preterm infants often have underdeveloped physical features. C) Labia widely separated with clitoris prominent indicates underdeveloped external genitalia common in preterm females. D) Breast area barely perceptible with flat areola, no bud signifies the lack of breast tissue development typical in preterm infants. E) Sole creases not extending the length of the foot is another sign of prematurity, as full-term infants usually have creases that cover at least two-thirds of the sole.

Question 19

The policy of the pediatric clinic is that head circumferences are performed at each visit, if appropriate. The nurse should plan to check head circumferences on which of the children being seen today? Standard Text: Select all that apply.

Accepted Answer

The answer of The policy of the pediatric clinic is...

Quiz 7: Pediatric and Newborn Assessment