Assessment of the Infant, Child, and Adolescent

1. 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.
ANS: B

Feedback
A Although this statement is true, the adolescent should have time alone with the nurse, if needed, to answer or ask personal questions.
B As children reach adolescence, they should be given the option to provide sensitive parts of the history without their parents present.
C Although this statement is true, the adolescent should have time alone with the nurse, if needed, to answer or ask personal questions.
D This intervention is not appropriate when the patient is present and able to answer questions. In addition, the parents may not know the information needed by the nurse about the adolescent.
DIF: Cognitive Level: Apply REF: 456
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communication

2. 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.
ANS: A

Feedback
A The American Academy of Pediatrics recommends positioning infants on their backs; the slogan to help people remember is “Back to Sleep.”
B The side-lying position is not recommended for sleep because of the risk of aspiration.
C Not feeding the baby for 3 hours before sleep is not a prevention for SIDS.
D The prone position is not recommended for sleep due to the risk of aspiration.
DIF: Cognitive Level: Apply REF: 458, Box 19-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion: Lifestyle Choices

3. 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?”
ANS: C

Feedback
A Asking the frequency of fast food or junk food consumption does not give data about what food is eaten.
B Knowing the amount of carbonated drinks provides more useful data.
C Adolescents should be asked specifically about their perception of their current weight and behaviors associated with eating disorders, including food restrictions, extreme diet/exercise routines, binging or purging, and the use of laxatives to screen for eating disorders.
D Knowing how frequently these foods are eaten provides more useful data.
DIF: Cognitive Level: Understand REF: 458
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health and Wellness

4. 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
ANS: C

Feedback
A These are developmental behaviors too advanced for a 3-year-old child.
B These are developmental behaviors too advanced for a 4-year-old child.
C These are developmental behaviors consistent with a 5-year-old child.
D These developmental behaviors are typically achieved and surpassed by a 6-year-old child.
DIF: Cognitive Level: Understand REF: 459
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

5. 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
ANS: D

Feedback
A Using adjectives such as these is not reliable to assess pain in patients of any age.
B This scale is appropriate for adolescents and adults, but a child cannot understand the concept of using numbers to rate pain.
C This type of scale is appropriate for adults, but a child cannot understand the concept of using a straight line to rate pain.
D This tool is appropriate for children who can point to the child’s face that best represents how they are feeling.
DIF: Cognitive Level: Apply REF: 459| 461-462
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

6. 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.
ANS: B

Feedback
A Rectal temperatures should be taken as a last resort because children tend to fear intrusive procedures and because of the risk for rectal perforation. The recommended sites for temperature measurement in newborns, infants, and children to age 5 are the axillary or tympanic sites.
B Infants usually breathe diaphragmatically, which requires observation of abdominal movement.
C For the older infant ( 6 months) and toddler, the nurse may find that having the caregiver hold the baby or toddler decreases fear and distress, thus making it easier for the nurse to conduct the examination.
D This infant is too young for blood pressure measurement. The National High Blood Pressure Education Program recommends that blood pressure be measured in children from age 3 through adolescence as part of routine health care visits.
DIF: Cognitive Level: Apply REF: 463
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

7. 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.”
ANS: D

Feedback
A This description refers to cavernous hemangioma that requires frequent reassessment.
B This description refers to a “stork bite” (telangiectasis).
C This is an inappropriate response.
D This description refers to a Mongolian spot.
DIF: Cognitive Level: Apply REF: 466
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

8. 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
ANS: C

Feedback
A A Mongolian spot appears as an irregularly shaped, darkened, flat area over the sacrum and buttocks.
B A stork bite (telangiectasis) is a common vascular birthmark that appears as a small red or pink spot often seen on the back of the neck.
C Port-wine stains appear as large, flat, bluish purple capillary areas. They are frequently found on the face along the distribution of the fifth cranial nerve (trigeminal).
D A strawberry hemangioma appears as a slightly raised, reddened area with a sharp demarcation line that may be 2 to 3 cm in diameter.
DIF: Cognitive Level: Apply REF: 466
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

9. 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.
ANS: C

Feedback
A The nurse measures chest circumference, but the tape measure is placed around the nipples rather than the ribs.
B An infant platform scale covered with a paper drape is used for weighing newborns, infants, and small children.
C The nurse measures head circumference using this procedure until about 2 years old.
D An infant’s height is measured while the infant is lying supine.
DIF: Cognitive Level: Apply REF: 467-468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

10. 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.
ANS: C

Feedback
A This is an incorrect technique.
B This is an incorrect technique.
C This is the correct technique for measuring head circumference.
D This is an incorrect technique.
DIF: Cognitive Level: Understand REF: 467
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

11. 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
ANS: B

Feedback
A This is not an expected motor skill for a 4-month-old; it is expected at 6 months of age.
B At four months of age, the head circumference should be larger than the chest circumference.
C This is a normal finding; infants generally double their birth weight by age 4 to 5 months.
D This is not an abnormal finding, especially if weight is normal; the height of the parents should also be considered.
DIF: Cognitive Level: Analyze REF: 467-468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

12. 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
ANS: A

Feedback
A This is a subperiosteal hematoma under the scalp that occurs secondary to birth trauma. The area, which appears as a soft, well-defined swelling over the cranial bone, generally is reabsorbed within the first month of life.
B Molding is secondary to the head passing through the birth canal and generally lasts less than a week.
C Cephalhematoma occurs over one cranial bone rather than several, and is well-defined rather than diffuse.
D Anterior fontanelles are soft but not depressed.
DIF: Cognitive Level: Understand REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

13. 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.
ANS: B

Feedback
A Microcephaly occurs when the head circumference is less than expected, which is not the finding here.
B The fontanelles frequently bulge when an infant is crying. The nurse will palpate the anterior and posterior fontanelles for fullness while the infant is in an upright position and calm.
C An elevated fontanelle when the infant is calm may indicate overhydration or fluid volume excess.
D Transillumination is not needed in this case.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

14. 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.”
ANS: D

Feedback
A This response refers to cephalohematoma, which is not described here.
B The newborn has molding that will resolve in a week.
C The newborn has molding that will resolve in a week.
D This is molding, which occurs when cranial bones override each other. Molding is secondary to the head passing through the birth canal and generally lasts less than a week.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

15. 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
ANS: A

Feedback
A The red reflex appears as a bright, round, red-orange glow seen through both pupils.
B Eyelid capillary hemangiomas are abnormalities that appear on the eyelid, but disappear spontaneously.
C Redness, lesions, nodules, discharge, or crusting of conjunctiva indicate conjunctivitis.
D Ophthalmia neonatorum is an eye disorder that produces purulent conjunctivitis and keratitis.
DIF: Cognitive Level: Apply REF: 468
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

16. What finding does a nurse expect when assessing a one-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
ANS: C

Feedback
A Testing for color vision occurs between ages 4 and 8 years.
B There are no tears until about 2 to 3 months of age.
C This is an accurate statement.
D The blink reflex is present in normal newborns and infants before one month.
DIF: Cognitive Level: Understand REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

17. 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
ANS: A

Feedback
A Presence of the red reflex eliminates the presence of most serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
B Symmetric corneal light reflex tests for symmetric eye muscle function and eliminates the presence of strabismus.
C Bilateral blink reflex tests the function of cranial nerve V (trigeminal).
D Symmetry of extraocular muscles tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens).
DIF: Cognitive Level: Understand REF: 468-469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

18. 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.
ANS: B

Feedback
A Performing the cover-uncover test is not indicated unless there is asymmetric light reflex after 6 months of age.
B Transient strabismus is common during the first few months of life due to a lack of binocular vision. If it continues after 6 months of age; however, a referral to an ophthalmologist is needed.
C The data do not support this interpretation.
D Referral is not needed unless the finding is present after the infant is 6 months old.
DIF: Cognitive Level: Apply REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

19. 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
ANS: D

Feedback
A A nurse uses the largest speculum that fits comfortably into the child’s ear canal.
B Because the nurse must have both hands free to hold the ear and maneuver the otoscope, another individual must act as a “holder.” The child’s head is turned to one side.
C The correct technique is to grasp the lower portion of the pinna and apply gentle traction down and slightly backward (as opposed to pulling the pinna up and back for the adult). This maneuver straightens the canal of the ear.
D Instruct the holder to secure the infant’s arms at the sides with one hand, and turn and hold the infant’s head to one side with the other hand.
DIF: Cognitive Level: Apply REF: 469
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

20. 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° 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.
ANS: A

Feedback
A This is the expected alignment of the ears and eyes of an infant.
B This is not an expected finding.
C This finding occurs in infants with Down syndrome.
D This is not an expected finding.
DIF: Cognitive Level: Understand REF: 470
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

21. 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
ANS: A

Feedback
A By age 4 to 6 months, an infant should turn the head toward the source of the sound and should respond to the parent’s voice.
B This behavior indicates an ability to hear loud noises.
C This is an expected finding for a child this age.
D Although an infant by age 4 to 6 months should respond to music toys, a disinterest does not indicate a hearing problem.
DIF: Cognitive Level: Understand REF: 470
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

22. 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
ANS: B

Feedback
A This is not an abnormal finding; occasionally, a natal loose tooth may be found.
B The infant’s tongue should be appropriate to the size of the mouth and fit well into the floor of the mouth.
C These small, white epithelial cells on the palate or gums are called Bohn nodules or Epstein pearls and are an expected finding.
D Whitish patches seen along the mucosa that scrape off easily are milk deposits. White patches that scrape off but leave a red area that may bleed indicate candidiasis lesions.
DIF: Cognitive Level: Apply REF: 471
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

23. 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
ANS: B

Feedback
A Sneezing is a common finding for an infant and is therapeutic because it helps to clear the nose.
B Coughing at this age is considered abnormal and indicates a problem.
C Infants use abdominal breathing rather than diaphragmatic breathing.
D Infants are obligate nose breathers until about 3 months old.
DIF: Cognitive Level: Understand REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

24. 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
ANS: B

Feedback
A Respiratory rate of 36 per minute in the newborn and infant is within the expected range of 30 to 60 breaths/min.
B Several respiratory findings indicate that an infant is in respiratory distress, including stridor, grunting, sternal or supraclavicular retractions, and nasal flaring.
C Infants are obligate nose breathers until about 3 months old.
D The respiratory pattern in the newborn may be irregular, having a Cheyne-Stokes type of pattern.
DIF: Cognitive Level: Understand REF: 471-472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

25. 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
ANS: C

Feedback
A The respiratory pattern in the newborn may be irregular, having a Cheyne-Stokes type of pattern.
B Unlike the adult, the infant has a round thorax with an equal anteroposterior and lateral diameter.
C Stridor and nasal flaring warrants immediate medical attention. Stridor is a high-pitched, piercing sound that is primarily heard in a distressed infant during inspiration.
D The predominant breath sound heard in the peripheral lung fields of infants is bronchovesicular.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

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.”
ANS: C

Feedback
A This is an expected weight gain for an infant.
B This is an expected sleep pattern for an infant.
C Heart problems are indicated when caregivers report the child stops eating to catch her breath.
D This finding may be related to the food eaten, rather than a cardiovascular problem.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

27. 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
ANS: B

Feedback
A This is a normal finding; capillary refill in infants is rapid—less than 1 second.
B This finding is abnormal because the apical pulse of the newborn normally is felt in the fourth or fifth intercostal space.
C Splitting of heart sounds is common in infants until about 48 hours after birth because of the transition from fetal circulation to systemic and pulmonic circulation.
D Acrocyanosis (cyanosis of hands and feet) without central cyanosis is of little concern and usually disappears within hours to days after birth.
DIF: Cognitive Level: Analyze REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

28. 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
ANS: D

Feedback
A The spleen is generally not palpable, although the tip may be felt in the left upper quadrant (far left costal margin).
B Inspecting the abdomen of a healthy infant finds a symmetric, soft, and round abdomen with a slight protrusion.
C The edge of the infant’s liver should be 1 to 2 cm below the right rib cage (costal margin).
D Diastasis swelling and a gap between the rectus muscles may be noted as an expect finding during crying.
DIF: Cognitive Level: Understand REF: 472
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

29. 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.
ANS: C

Feedback
A Normal findings include stable and smooth clavicles, without crepitus.
B The Barlow-Ortolani maneuver assesses hip location.
C The Barlow-Ortolani maneuver assesses hip location, and the movement should feel smooth and produce no clicking.
D The feet should be flexible and not fixed. Normally, the hindfoot aligns with the lower leg and the forefoot turns inward slightly.
DIF: Cognitive Level: Understand REF: 473
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

30. 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).
ANS: A

Feedback
A This describes the Barlow-Ortolani maneuver to assess hip location and determine dislocation.
B This describes an incorrect technique.
C This describes an incorrect technique.
D This describes an incorrect technique.
DIF: Cognitive Level: Apply REF: 473
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

31. 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
ANS: C

Feedback
A This is an expected finding. Bulging fontanelle is a manifestation of hydrocephalus.
B By 4 months old, most infants demonstrate head control by holding the head erect and midline when in an upright position.
C The abnormal accumulation of cerebrospinal fluid increases the head circumference because the sutures of the skull are not ossified and the anterior fontanelle is not closed.
D Marked asymmetry of the head may indicate craniosynostosis, a premature ossification of one or more of the cranial sutures.
DIF: Cognitive Level: Understand REF: 475
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

32. 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.
ANS: B

Feedback
A The arms and legs flex and extend, rather than abduct and adduct.
B This is the expected response for the tonic neck reflex that appears from birth to 6 weeks old and disappears at 4 to 6 months old.
C This is not an expected finding for any infant reflexes.
D This is a description of the sucking reflex.
DIF: Cognitive Level: Apply REF: 474
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

33. 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
ANS: D

Feedback
A This is not an expected response from any reflex.
B This is not an expected response from any reflex.
C This is part of the clonus reflex test.
D This is the expected response for the Babinski reflex.
DIF: Cognitive Level: Apply REF: 474-475
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

34. 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.
ANS: B

Feedback
A This response is premature without determining if the testicle can be manually descended into the scrotum.
B If the testicle can be pushed into the scrotum, it is considered descended even though it retracts into the inguinal canal.
C Transillumination is used to detect a hydrocele, which is a common finding in infants but not related to an undescended testicle.
D This response is not appropriate.
DIF: Cognitive Level: Analyze REF: 476
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

35. 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.
ANS: D

Feedback
A This child has a stork bite birthmark on the back of the neck and an upper respiratory allergy or viral infection.
B This is a strawberry hemangioma, a birthmark that disappears by 5 years of age.
C This child probably fell down while running, skinned both knees, and tried to break the fall with the hands.
D Bruising in unusual areas (such as upper arms, back, buttocks, and abdomen) or multiple bruises found at different stages of healing should be further investigated to determine if there is abuse.
DIF: Cognitive Level: Analyze REF: 477
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

36. 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
ANS: B

Feedback
A Vision can be assessed when performing developmental tests such as the Denver II, but the Snellen E provides more objective data.
B Use the Snellen E chart for children 3 to 6 years of age (see Chapter 11). Have children point their fingers in the direction of the “arms” of the E.
C Use the Allen picture cards to screen for visual acuity in 2.5- to 3-year-old children.
D The Snellen standard chart is used for adolescents and adults; it is too difficult to use for children.
DIF: Cognitive Level: Understand REF: 478
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

37. 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
ANS: D

Feedback
A The term “shotty” may be used to describe small, firm, and mobile nodes, usually occurring as a normal variation in children.
B Cervical and submandibular nodal enlargements are frequent in older children.
C Enlarged, tender nodes may occur after immunizations or upper respiratory infection.
D Abnormal findings are tender, fixed nodes greater than 1 cm.
DIF: Cognitive Level: Analyze REF: 479-480
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

38. 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
ANS: D

Feedback
A At this age, children have a nasal and abdominal breathing pattern and do not develop a thoracic breathing pattern until 6 or 7 years of age.
B By age 5 or 6, the rounded thorax of the child approximates the 1:2 ratio of anteroposterior to lateral diameter of the adult.
C By age 6 or 7, the child’s breathing pattern should change from primarily nasal and abdominal to thoracic in girls and abdominal in boys.
D Although bronchovesicular breath sounds in peripheral lung areas are expected in a young child, vesicular sounds are expected at this age.
DIF: Cognitive Level: Analyze REF: 480
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

39. 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
ANS: C

Feedback
A An expected finding in children is a venous hum in the jugular vein.
B This is an expected resting heart rate for a child; the expected range for a toddler is from 80 to 110 and for a school-age child from 60 to 110 beats/min.
C Squatting may be a compensatory position for a child with a heart defect.
D This is an expected finding.
DIF: Cognitive Level: Analyze REF: 481
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

40. 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
ANS: A

Feedback
A Toddlers normally exhibit a rounded (potbelly) abdomen while both standing and lying down.
B The nurse needs to collect more data before making this recommendation.
C The nurse needs to collect more data before making this recommendation.
D This is an inappropriate statement based on the description of this child.
DIF: Cognitive Level: Apply REF: 481
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

41. 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
ANS: D

Feedback
A Trendelenburg sign (or gait) tests for hip dysplasia and the function of the gluteus medius muscle.
B Lordosis is seen more frequently in African American children but should not be seen in children older than 6 years of age.
C Varus rotation (medial malleolus touching with knees greater than 1 inch [2.5 cm] apart) requires further evaluation for tibial torsion; it may be normal through 18 to 24 months of age.
D Valgus rotation (medial malleolus greater than 1 inch [2.5 cm] apart with knees touching) is normal in 2- to 3.5-year-old children and may be present up to 12 years old.
DIF: Cognitive Level: Understand REF: 482
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

42. 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
ANS: C

Feedback
A Vaginal discharge is an abnormal finding at this age.
B Normally at this age the clitoris is relatively small.
C Until approximately age 7, the labia majora are flat, the labia minora are thin.
D Evidence of pubic hair may be seen by the time the child reaches pubescence, usually between ages 8 and 11.
DIF: Cognitive Level: Understand REF: 485
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

43. 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
ANS: C

Feedback
A The examination is easiest to perform if the child is sitting.
B The examination is easiest to perform if the child is sitting.
C The examination is easiest to perform if the child is sitting in either a slightly reclining position with his knees flexed or heels near the buttock or sitting with his knees spread and ankles crossed.
D The examination is easiest to perform if the child is sitting.
DIF: Cognitive Level: Understand REF: 485
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

44. 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
ANS: C

Feedback
A Screening for muscle weakness in a well adolescent is not indicated.
B Screening for limited range of motion in a well adolescent is not indicated.
C Adolescents are screened for scoliosis, kyphosis, and lordosis. Postural kyphosis is almost always accompanied by a compensatory lordosis, an abnormally concave lumbar curvature.
D Adolescents are screened for scoliosis.
DIF: Cognitive Level: Understand REF: 486-487
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development

45. 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.”
ANS: A

Feedback
A The right and left breasts may develop at different rates. It is important to reassure the patient that this is common and, in time, the development may equalize. Full development of the breast takes an average of 3 years (range 1.5 to 6 years).
B Breasts may develop at different rates.
C Menarche begins when the breasts reach Tanner stages 3 or 4, which is approximately age 12.
D Precocious breast development is the development of breasts before 8 years old.
DIF: Cognitive Level: Apply REF: 487
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Growth and Development