The nurse is performing a physical assessment on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). The parent is concerned about the child's ability to cooperate during the examination. Place the components of assessment in the order the nurse would perform them. All options must be used.

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Always complete the assessment by performing the least invasive parts first and then progressing to the most invasive. By first establishing a rapport with the parent (Option B), the nurse will elicit the child's trust and cooperation. Playing with the child will help the child relax and perceive the nurse as less of a threat (Option D). Measuring the child's height and weight should be performed next (Option C). Auscultation of the heart and lungs should then be performed. Allowing the child to play with the equipment first will make this part of the assessment easier (Option A). Taking vital signs can be difficult as a blood pressure cuff can be perceived as painful (Option E); once the child is upset, it becomes difficult to continue with the assessment. A temperature of 101.7 F (38.7 C) is not serious in a child, especially if there are signs and symptoms of an upper respiratory infection. Educational objective: Performing a physical assessment in a toddler can be challenging. The nurse should establish a rapport with the parent and then attempt to gain the child's trust. Playing with the child can make the experience easier on the nurse, parents, and child. The nurse should always perform the least invasive procedures first, explain them in simple terms, and praise the child throughout the assessment.

The Nurse Is Performing a Physical Assessment on a 2-Year-Old