Deck 19: Assessment of the Infant, Child, and Adolescent

Question 1

A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient?

A) Asking him if the pain hurts "a little or a lot"
B) Asking him to rate the pain on a scale of 0 to 10
C) Using the visual analog scale to rate the pain
D) Using the Wong/Baker FACES rating scale

Answer 1

Using the Wong/Baker FACES rating scale

Question 2

Which finding rules out defects in the cornea, lens, and vitreous chamber of an infant?

A) Bilateral red reflex
B) Symmetric corneal light reflex
C) Bilateral blink reflex
D) Symmetric eye movements

Answer 2

Bilateral red reflex

Question 3

An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate's sacrum and buttocks. What is the nurse's most appropriate response to this mother?

A) "This area will continue to grow until the infant is 10 to 15 months old."
B) "This is a birth mark, which usually disappears by age 5 years."
C) "This skin abnormality will require follow-up care."
D) "This is a birth mark and they usually disappear by age 1 or 2 years."

Answer 3

"This is a birth mark and they usually disappear by age 1 or 2 years."

Question 4

During a well-baby check for several 4-month-old infants, a nurse recognizes that which infant needs further assessment of an abnormal finding?

A) The infant who is unable to sit independently
B) The infant whose head circumference and chest circumference are equal
C) The infant whose weight has doubled since birth
D) The infant whose length falls in the 90th percentile on growth charts

Question 5

A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age?

A) 3 years old
B) 4 years old
C) 5 years old
D) 6 years old

Question 6

In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the infant's eyes and notices that the light reflection is not in the same location in each eye. What is the nurse's most appropriate response to this finding?

A) Perform the cover-uncover test.
B) Document it as an expected finding at this age.
C) Document abnormal function of cranial nerves IV (trochlear) and VI (abducens).
D) Refer the infant to an ophthalmologist.

Question 7

Which assessment technique is appropriate to measure the 8-month-old's vital signs during a well-baby check?

A) Assess temperature using a rectal thermometer.
B) Observe the infant's abdomen when counting respirations.
C) Take the infant from the parent's arms to assess pulse.
D) Measure blood pressure in the leg.

Question 8

An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse's most appropriate intervention?

A) Tell the patient that it is very important to be honest and specific.
B) Provide time when the adolescent is alone with the nurse.
C) Reassure the patient that anything said in the interview is considered confidential.
D) Ask the parents to answer the questions if the patient is not willing to answer.

Question 9

Which finding indicates to a nurse that a neonate has a cephalhematoma?

A) Well-defined edematous area over one cranial bone
B) Molding of the cranium that causes generalized cerebral edema
C) Diffuse edema over two or more cranial bones
D) Anterior fontanelle that is deeply depressed

Question 10

How does a nurse document a large, flat bluish capillary area on a neonate's cheek?

A) Mongolian spot
B) Stork bite (telangiectasis)
C) Port-wine stain (nevus flammeus)
D) Strawberry hemangioma

Question 11

A mother who sees her newborn just after vaginal delivery is distraught because the child's head is elongated. Which response is most appropriate by the nurse?

A) "This is due to a small area of bleeding that will go away in 1 to 2 months."
B) "This may indicate a congenital deformity; the pediatrician will evaluate this."
C) "This will require surgery to prevent hydrocephalus from developing."
D) "This is not unusual after a vaginal delivery and will go away in about a week."

Question 12

What technique does a nurse use to inspect the ear canal of a 1-year-old child?

A) Uses a light source without a speculum to minimize any trauma to the ear canal
B) Places the child in an upright position with the head flexed slightly downward
C) Applies gentle traction to the lower portion of the ear and pulls upward and laterally
D) Uses an assistant to hold the child's arms down and keep the child's head turned to one side

Question 13

In inspecting the eyes and ears of an infant, the nurse documents which finding as normal?

A) The external ear is in direct line with the outer margin of the eyelid.
B) The ear lobe is within 10 degrees of alignment with the outer margin of the eyelid.
C) A lateral upward slant of the eyes aligns them with the helix of the ear.
D) The inner margin of the eye is directly aligned with the helix of the ear.

Question 14

During assessment of an infant, the nurse notes that when the infant cries, the fontanelles bulge slightly. What is the most appropriate action for the nurse at this time?

A) Note in the record that the child is microcephalic.
B) Assess the fontanelles again when the child is not crying.
C) Check the child for signs of malnutrition and dehydration.
D) Use transillumination for further assessment of the skull.

Question 15

How does a nurse assess the head circumference of an infant?

A) Places a ruler behind the infant's head, noting the head width
B) Uses a plastic headband placed around the infant's head from crown to chin
C) Places a measuring tape around the head above the eyebrows and occipital prominence
D) Uses a measuring tape to find the distance between the ears and eyes and between the eyes and occiput

Question 16

What finding does a nurse expect when assessing a 1-month-old's eyes and vision?

A) The newborn distinguishes most colors
B) Tears when the newborn cries
C) The newborn following a bright toy or light
D) The newborn's blink reflex is present

Question 17

How does a nurse collect baseline measurements of a 6-month-old infant?

A) Measure the chest circumference around the lower ribs.
B) Ask the parent how much the infant's weight has changed since birth.
C) Measure the head just above the ears and eyebrows.
D) Ask the parent to hold the infant while the nurse measures the length.

Question 18

In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question?

A) "How frequently do you eat fast food or junk food?"
B) "Which carbonated drinks do you drink most often?"
C) "Do you have any food restrictions or diet routines?"
D) "What are your favorite fruits and vegetables?"

Question 19

A nurse shines the light from the ophthalmoscope into the eyes of a newborn and observes a bright, round, red-orange glow seen through both pupils. How does the nurse document this finding?

A) An expected red reflex
B) Eyelid capillary hemangiomas
C) Bilateral conjunctivitis
D) Ophthalmia neonatorum

Question 20

What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)?

A) Place the baby on back to sleep.
B) Place the baby on side to sleep.
C) Not to feed the baby for 3 hours before sleep.
D) Place the baby on her stomach to sleep.

Question 21

How does a nurse respond to parents of a 5-year-old who are worried that their child has a protruding abdomen?

A) Assesses the child to differentiate a normal "potbelly" from a hernia
B) Suggests that the parents administer an appropriate dose of a laxative at bedtime
C) Refers the parents to a nutritionist to develop an appropriate weight-loss diet for the child
D) Informs the parents that a protruding abdomen is always an abnormal finding in this age group

Question 22

Which behavior would be most indicative of hearing impairment in a 1-year-old child?

A) Failure to respond to mother's voice
B) Crying when a loud noise occurs unexpectedly
C) Saying only single-syllable words
D) Disinterest in playing with musical toys

Question 23

The nurse suspects respiratory distress in a newborn infant who exhibits which manifestation?

A) Respiratory rate of 36 breaths/min
B) Sternal retractions
C) Nasal breathing
D) Irregular breathing pattern

Question 24

The nurse documents which finding as normal after performing the Barlow-Ortolani maneuver on an infant?

A) The clavicles are immobile and without crepitus.
B) Each shoulder remains in a "hunched up" position.
C) No clicking is noted when the hips are abducted and adducted.
D) Both feet are held in the varus position when stroked on the soles.

Question 25

Which tool is most appropriate for testing the vision of a 5-year-old child?

A) Denver II test
B) Snellen E chart
C) Allen picture cards
D) Snellen standard chart

Question 26

Which statement by a mother makes the nurse assess the infant girl for cardiovascular problems?

A) "She has gained 2 lb since our last visit."
B) "She naps twice a day for almost 2 hours each time."
C) "She gets so tired and out of breath when she takes her bottle."
D) "She gets fussy after I feed her and seems to have lots of gas."

Question 27

In performing a respiratory assessment of a 1-month-old infant, the nurse recognizes which finding as abnormal?

A) Sneezing
B) Coughing
C) Abdominal breathing
D) Predominantly nose breathing

Question 28

Which technique does a nurse use to assess hip location of a newborn?

A) With newborn's knees flexed, the nurse adducts the legs, then abducts them, moving the knees apart and down to touch the table.
B) With the newborn supine, the nurse flexes and extends the hips, and then passively moves each leg through internal and external rotation.
C) The nurse holds the newborn in a vertical position with the feet flat on the table and palpates each hip for location.
D) With the newborn supine, the nurse measures the length of each leg from the trochanter to the lateral malleolus (ankle).

Question 29

To assess the reflexes of a 5-month-old infant lying supine, the nurse turns the infant's head to the left side so that the chin is over the shoulder. What is the expected response for this reflex?

A) Left arm and leg abduct and the right arm and leg adduct.
B) Left arm and leg extend and the right arm and leg flex.
C) Infant turns the chin from the left to the right side.
D) Infant begins a sucking motion with the lips and tongue.

Question 30

A nurse refers which child for further assessment?

A) A 2-year-old who has a jugular venous hum after playing
B) A 4-year-old who has a resting heart rate of 100
C) A 5-year-old who positions herself in a squat after running a few feet
D) A 7-year-old who has a strong femoral pulse readily detected on palpation

Question 31

During the assessment of a newborn within hours after birth, a nurse determines which finding as abnormal?

A) Capillary refill time of less than 1 second
B) Apical pulse felt at the second intercostal space
C) Splitting of heart sounds
D) Cyanosis of the hands and feet

Question 32

A nurse tests a reflex on a 9-month-old infant's right foot by stroking the surface of the infant's foot, moving from the sole laterally up and across to the great toe. What is the expected response?

A) Flexion of the right toes
B) Extension of the right ankle
C) Dorsiflexion of the right foot
D) Fanning of the toes of the right foot

Question 33

When examining lymph nodes in a 7-year-old child, the nurse records which finding as abnormal?

A) Shotty nodes in the cervical areas
B) Palpable submandibular nodes
C) Nodes that are tender 1 week after a tetanus vaccination
D) Tender, fixed nodes greater than 1 cm

Question 34

After obtaining a history from the parents and inspecting the skin, the nurse determines which child needs further evaluation?

A) The child who has a 1-cm red spot on the back of the neck, a fever of 100° F, and clear nasal drainage.
B) The child who has a 2-cm slightly raised, reddened area with a sharp demarcation line on the back of the neck.
C) The child has a 2-cm abrasion on the right knee, a 3-cm abrasion on the left knee, and scrapes on both palms.
D) The child who has several flat, bluish discolorations of the skin on the abdomen and back from 2 to 6 cm.

Question 35

In assessing a neonate, the nurse notices that one testicle has not descended into the scrotal sac. What is the most appropriate response for the nurse as a result of this finding?

A) Document the findings and refer this neonate for further examination for an undescended testicle.
B) Place a finger over the upper inguinal ring and gently push downward to try to push the testicle into the scrotum.
C) Use a light source to transilluminate the affected scrotal sack to determine if fluid is preventing the descent of the testicle.
D) Insert the fifth finger into the inguinal ring to palpate for a hernia that may have prevented the testicle from descending.

Question 36

A nurse assessing a 3-month-old infant suspects hydrocephalus based on which finding?

A) Soft anterior fontanelle
B) Lack of head control while sitting
C) Increasing head circumference
D) Marked asymmetry of the head

Question 37

On assessment of an infant's abdomen, the nurse notes which finding as normal?

A) Easily palpable spleen
B) Flat to slightly concave abdominal contour
C) Lower liver border 2 inches below the costal margin
D) Small protrusion between the rectus muscles when crying

Question 38

Which finding during inspection of the mouth of a 1-month-old infant requires further investigation?

A) A small loose tooth in the lower jaw
B) Tongue overlapping the floor of the mouth
C) Whitish epithelial cells on the roof of the mouth
D) White patches on the tongue that scrape off easily

Question 39

After assessment of each child, the nurse determines which child needs to be referred for further evaluation?

A) A 4-year-old child with a predominantly nasal breathing pattern
B) A 6-year-old child with a 1:2 anteroposterior-to-transverse-chest ratio
C) A 7-year-old child with a predominantly thoracic breathing pattern
D) A 9-year-old child with bronchovesicular breath sounds in peripheral lungs

Question 40

When assessing an infant, the nurse recognizes which finding requires immediate attention?

A) Cheyne-Stokes type of respiratory pattern
B) 1:1 anteroposterior to lateral chest diameter
C) Stridor and nasal flaring
D) Bronchovesicular lung sounds in the periphery

Question 41

While examining the genitalia of a 6-year-old girl, a nurse notices which finding as expected?

A) Clear mucoid vaginal discharge
B) Prepuce and clitoris are prominent.
C) Flat labia majora with thin labia minora
D) Sparse pubic hair over the inner thighs

Question 42

During a musculoskeletal assessment of a school-age child, a nurse documents which finding as expected?

A) A positive Trendelenburg sign on one side
B) Lumbar lordosis, especially in African-American children
C) Varus rotation when the knees are greater than 1 inch apart
D) Valgus rotation of less than 1 inch with the knees touching

Question 43

Which disorder, if any, does a nurse screen for when examining a healthy adolescent?

A) Muscle weakness.
B) Limited joint range of motion.
C) Curvature of the spine.
D) No screening is needed when the adolescent is healthy.

Question 44

During a physical examination, a 12-year-old girl expresses concern to the nurse that her breasts are different sizes. Which response is most appropriate for the nurse?

A) "This happens normally to many girls your age. Full breast development takes an average of 3 years."
B) "I can talk with your mother about a referral to a physician who can perform further examination and tests."
C) "Have you started your menstrual period yet, because breast development is irregular until menstruation begins?"
D) "This is called 'precocious breast development' and your breasts will become more equal just before your growth spurt starts."

Question 45

The nurse places an 8-year-old boy in which position for examination of his genitalia?

A) Supine with legs extended to either side
B) Lying on his left side with knees bent
C) Reclining with knees flexed
D) Standing with legs spread apart