The nurse is performing a well-child assessment on a sleeping 2-month-old client. Organize the assessment in the correct order based on the developmental age of the client. All options must be used.

Question

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The sequence of examination steps for infants requires a different approach than the typical head-to-toe order used for older clients. The steps are altered to accommodate the developmental needs of the infant, minimize the infant's stress, and increase assessment accuracy. The correct order of assessment in infants is: Before handling the infant, the nurse first observes the infant for activity level, skin color, and respiratory rate and pattern to obtain findings during a calm state (Option D). Auscultation is performed next while the infant is still quiet, allowing the nurse to hear sounds clearly (Option B). Palpation and percussion are then performed while the infant remains relatively still. This allows the nurse to accurately assess the abdomen while the abdominal muscles are relaxed. The fontanelles are also palpated while the infant is calm, as crying can cause temporary bulging (Option E). Traumatic procedures (eg, examine eyes, ears, mouth) are performed near the end of the assessment after completing any procedures that require accurate observation or counting (Option A). Elicitation of the Moro reflex (ie, reflexive startle and cry to a sudden dropping or jarring motion) is performed last because the infant is usually awake and moving around by this point (Option C). Educational objective: When assessing an infant, the nurse should observe, auscultate, palpate, and then perform traumatic procedures (eg, examine eyes, ears, mouth). Elicitation of the Moro reflex should be performed last.

The Nurse Is Performing a Well-Child Assessment on a Sleeping