Assessment Of The Infant, Child, And Adolescent

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Question 1

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Multiple Choice

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

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Tell the patient that it is very important to be honest and specific.

Provide time when the adolescent is alone with the nurse.

Reassure the patient that anything said in the interview is considered confidential.

Ask the parents to answer the questions if the patient is not willing to answer.

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Question 2

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Multiple Choice

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

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Place the baby on back to sleep.

Place the baby on side to sleep.

Not to feed the baby for 3 hours before sleep.

Place the baby on her stomach to sleep.

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Question 3

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Multiple Choice

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

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"How frequently do you eat fast food or junk food?"

"Which carbonated drinks do you drink most often?"

"Do you have any food restrictions or diet routines?"

"What are your favorite fruits and vegetables?"

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Question 4

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Multiple Choice

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?

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3 years old

4 years old

5 years old

6 years old

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Question 5

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Multiple Choice

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?

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Asking him if the pain hurts "a little or a lot"

Asking him to rate the pain on a scale of 0 to 10

Using the visual analog scale to rate the pain

Using the Wong/Baker FACES rating scale

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Question 6

Multiple Choice

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

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Assess temperature using a rectal thermometer.

Observe the infant's abdomen when counting respirations.

Take the infant from the parent's arms to assess pulse.

Measure blood pressure in the leg.

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Question 7

Multiple Choice

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?

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"This area will continue to grow until the infant is 10 to 15 months old."

"This is a birth mark, which usually disappears by age 5 years."

"This skin abnormality will require follow-up care."

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

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Question 8

Multiple Choice

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

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Mongolian spot

Stork bite (telangiectasis)

Port-wine stain (nevus flammeus)

Strawberry hemangioma

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Question 9

Multiple Choice

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

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Measure the chest circumference around the lower ribs.

Ask the parent how much the infant's weight has changed since birth.

Measure the head just above the ears and eyebrows.

Ask the parent to hold the infant while the nurse measures the length.

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Question 10

Multiple Choice

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

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Places a ruler behind the infant's head, noting the head width

Uses a plastic headband placed around the infant's head from crown to chin

Places a measuring tape around the head above the eyebrows and occipital prominence

Uses a measuring tape to find the distance between the ears and eyes and between the eyes and occiput

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Question 11

Multiple Choice

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

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The infant who is unable to sit independently

The infant whose head circumference and chest circumference are equal

The infant whose weight has doubled since birth

The infant whose length falls in the 90th percentile on growth charts

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Question 12

Multiple Choice

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

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Well-defined edematous area over one cranial bone

Molding of the cranium that causes generalized cerebral edema

Diffuse edema over two or more cranial bones

Anterior fontanelle that is deeply depressed

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Question 13

Multiple Choice

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?

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Note in the record that the child is microcephalic.

Assess the fontanelles again when the child is not crying.

Check the child for signs of malnutrition and dehydration.

Use transillumination for further assessment of the skull.

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Question 14

Multiple Choice

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?

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"This is due to a small area of bleeding that will go away in 1 to 2 months."

"This may indicate a congenital deformity; the pediatrician will evaluate this."

"This will require surgery to prevent hydrocephalus from developing."

"This is not unusual after a vaginal delivery and will go away in about a week."

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Question 15

Multiple Choice

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?

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An expected red reflex

Eyelid capillary hemangiomas

Bilateral conjunctivitis

Ophthalmia neonatorum

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Question 16

Multiple Choice

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

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The newborn distinguishes most colors

Tears when the newborn cries

The newborn following a bright toy or light

The newborn's blink reflex is present

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Question 17

Multiple Choice

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

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Bilateral red reflex

Symmetric corneal light reflex

Bilateral blink reflex

Symmetric eye movements

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Question 18

Multiple Choice

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?

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Perform the cover-uncover test.

Document it as an expected finding at this age.

Document abnormal function of cranial nerves IV (trochlear) and VI (abducens).

Refer the infant to an ophthalmologist.

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Question 19

Multiple Choice

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

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Uses a light source without a speculum to minimize any trauma to the ear canal

Places the child in an upright position with the head flexed slightly downward

Applies gentle traction to the lower portion of the ear and pulls upward and laterally

Uses an assistant to hold the child's arms down and keep the child's head turned to one side

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Question 20

Multiple Choice

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

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The external ear is in direct line with the outer margin of the eyelid.

The ear lobe is within 10 degrees of alignment with the outer margin of the eyelid.

A lateral upward slant of the eyes aligns them with the helix of the ear.

The inner margin of the eye is directly aligned with the helix of the ear.

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