CHAPTER 14: PEDIATRIC ASSESSMENT My Nursing Test Banks

CHAPTER 14: PEDIATRIC ASSESSMENT

MULTIPLE CHOICE

1.When infants are born prematurely, the chronological age on the growth chart:

a.

is the same as for other children after 6 months

b.

is not accurate, and a special chart for preemies must be used

c.

must be corrected subtracting weeks or months of prematurity until age 18 months old

d.

must be corrected until age 18, subtracting the period of prematurity from the age

ANS: C

Feedback

A

Incorrect. When infants are born prematurely, the chronological age on the growth chart is not the same as for other children after 6 months.

B

Incorrect. When infants are born prematurely, the chronological age on the growth chart is not accurate, but you use the same growth chart.

C

Correct. When infants are born prematurely, the chronological age on the growth chart must be corrected subtracting weeks or months of prematurity until age 18 months old.

D

Incorrect. When infants are born prematurely, the chronological age on the growth chart must be corrected until age 18 (months or years, not specified).

PTS:1REF:p. 435 Health History

OBJ: Cognitive Level: Comprehension

2.When you are the nurse taking the health history of a child, the historian is most likely going to be an adult. Which of the following questions would be the most important to ask before admitting or treating the child?

a.

What is the birth date of the child?

b.

Who is the legal guardian?

c.

What is your relationship to the child?

d.

What problems occurred during pregnancy?

ANS: B

Feedback

A

Incorrect. When taking the health history of a child, the most important question to ask is not: What is the birth date of the child?

B

Correct. When taking the health history of a child, the most important question to ask before admitting or treating the child after the childs name is: Who is the legal guardian?

C

Incorrect. When taking the health history of a child, the most important question to ask is not: What is your relationship to the child?

D

Incorrect. When taking the health history of a child, the most important question to ask is not: What problems occurred during pregnancy?

PTS:1REF:p. 435 Health History

OBJ: Cognitive Level: Application

3.The nurse is talking with the caregivers about a childs developmental and health history. The child interrupts to add something and the caregivers direct the child to be quiet. The nurses best course of action would be based mostly on which of the following ideas?

a.

Caregivers have the right to govern their own children.

b.

Children are not as accurate as caregivers in the recall of developmental and health histories.

c.

Children need to be included in their own health care as much as possible, considering age and development.

d.

The caregivers are the decision makers in terms of care and will be paying for the cost of the care.

ANS: C

Feedback

A

Incorrect. While taking a health history, in the event the child interrupts to add some detail, the nurses best course of action would not be based on the idea that caregivers have the right to govern their own children, and thus be allowed to direct the child to be quiet.

B

Incorrect. While taking a health history, in the event the child interrupts to add some detail, the nurses best course of action would not be based on the idea that children are not as accurate as caregivers in the recall of developmental and health histories.

C

Correct. Because the historian in a pediatric history is less often the child and most likely the caregiver, it is very important to document the caregivers relationship to the child. The child should be included in the history taking as appropriate for her or his age and development.

D

Incorrect. While taking a health history, in the event the child interrupts to add some detail, the nurses best course of action would not be based on the idea that the caregivers are the decision makers in terms of care and will be paying for the cost of the care.

PTS:1REF:p. 436 Health History

OBJ: Cognitive Level: Application

4.A mother tells you that her 4-year-old child has begun to have night waking and has started thumb sucking again. Otherwise the child seems very healthy. From this brief history, your immediate response is:

a.

It is normal for preschool-aged children to go through some short periods of regression.

b.

What changes have happened in your family or with your child?

c.

Is there any possibility of pinforms or some other type of parasite that your child might have?

d.

You need to call your pediatrician right away and get a complete physical on this child.

ANS: B

Feedback

A

Incorrect. When a mother tells you that her 4-year-old child has begun to have night waking and has started thumb sucking again, your immediate response will not be: It is normal for preschool-aged children to go through some short periods of regression. This response ends the discovery of what is causing this regression.

B

Correct. When a mother tells you that her 4-year-old child has begun to have night waking and has started thumb sucking again, you will suspect that the child may be experiencing stress, and respond: What changes have happened in your family or with your child?

C

Incorrect. When a mother tells you that her 4-year-old child has begun to have night waking and has started thumb sucking again, your immediate response would not focus on the sleeplessness and possibility of pinforms.

D

Incorrect. When a mother tells you that her 4-year-old child has begun to have night waking and has started thumb sucking again, your immediate response would not be: You need to call your pediatrician right away and get a complete physical on this child. This response ends the discovery of what is causing this regression.

PTS:1REF:p. 434 Pediatric Assessment

OBJ: Cognitive Level: Application

5.When obtaining a childs past health history, the nurse would ask questions aimed at getting pertinent information, beginning with the:

a.

Apgar score and birth itself

c.

labor and delivery

b.

postnatal period

d.

prenatal period

ANS: D

Feedback

A

Incorrect. When obtaining a childs past health history, the nurse would ask questions aimed at getting pertinent information, but not beginning with the Apgar score and birth itself.

B

Incorrect. When obtaining a childs past health history, the nurse would ask questions aimed at getting pertinent information, but not beginning with the postnatal period.

C

Incorrect. When obtaining a childs past health history, the nurse would ask questions aimed at getting pertinent information, but not beginning with the labor and delivery.

D

Correct. When obtaining a childs past health history, the nurse would ask questions aimed at getting pertinent information, beginning with the prenatal period.

PTS:1REF:p. 435 Health History

OBJ: Cognitive Level: Comprehension

6.When taking the health history of a child whose family is at the poverty level and has no insurance, you discover that the child has been seen in the emergency room of the hospital ten times in the last 6 months. During the interview, you would first try to find out from the family if:

a.

they use the emergency room for episodic health care or if the child has a regular health care provider

b.

there is a history of child or spousal abuse or incestuous relationships in the family

c.

the child has a chronic health problem with acute exacerbations presenting an emergency situation

d.

the child is hyperactive or has a history of inattention to safety and suffers accidents on a regular basis

ANS: A

Feedback

A

Correct. Upon the discovery that the child has been seen in the emergency room of the hospital ten times in the last 6 months, you would first try to find out from the family if they use the emergency room for episodic health care or if the child has a regular health care provider.

B

Incorrect. Upon the discovery that the child has been seen in the emergency room of the hospital ten times in the last 6 months, you would not first try to find out from the family if there is a history of child or spousal abuse or incestuous relationships in the family.

C

Incorrect. Upon the discovery that the child has been seen in the emergency room of the hospital ten times in the last 6 months, you would not first try to find out from the family if the child has a chronic health problem with acute exacerbations presenting an emergency situation.

D

Incorrect. Upon the discovery that the child has been seen in the emergency room of the hospital ten times in the last 6 months, you would not first try to find out from the family if the child is hyperactive or has a history of inattention to safety and suffers accidents on a regular basis.

PTS:1REF:p. 435 Health History

OBJ: Cognitive Level: Application

7.Which of the following questions or statements is most important during the health history interview of the family seeking care for a toddler?

a.

What does your child prefer to eat?

b.

When did your child say the first word?

c.

Tell me about the toilet training and how that is going.

d.

Tell me how you have childproofed your home.

ANS: D

Feedback

A

Incorrect. During the health history interview of the family seeking care for a toddler, the question What does your child prefer to eat? is not among the most important.

B

Incorrect. During the health history interview of the family seeking care for a toddler, the question When did your child say the first word? is not among the most important.

C

Incorrect. During the health history interview of the family seeking care for a toddler, the question Tell me about the toilet training and how that is going. is not among the most important.

D

Correct. During the health history interview of the family seeking care for a toddler, a most important question is: Tell me how you have childproofed your home.

PTS:1REF:p. 437 Nutritional Assessment

OBJ: Cognitive Level: Application

8.A mother asks the nurse to tell her the normal amount of milk a bottle-feeding infant takes in per day in the first month after birth. The nurses answer would be that an infant at this age would take up to:

a.

32 ounces

c.

56 ounces

b.

46 ounces

d.

64 ounces

ANS: A

Feedback

A

Correct. Responding to a mothers question about the normal amount of milk a bottle-feeding infant takes in per day in the first month after birth, the nurses answer would be that an infant at this age would take up to 32 ounces per day.

B

Incorrect. The nurses answer would not be that an infant at this age would take up to 46 ounces per day.

C

Incorrect. The nurses answer would not be that an infant at this age would take up to 56 ounces per day.

D

Incorrect. The nurses answer would not be that an infant at this age would take up to 64 ounces per day.

PTS:1REF:p. 438 Nutritional Assessment

OBJ: Cognitive Level: Comprehension

9.During a talk with the nurse, the mother of a 6-month-old baby says that she gets her to go to sleep by giving her a bottle of milk to suck on until she falls asleep. The nurses best response would be:

a.

You need to be watching your baby on a monitor or there the baby cannot see you.

b.

Be sure you prop the bottle well and the babys head is slightly elevated.

c.

Letting a child fall asleep with a bottle of milk or other liquid containing sugar will cause cavities.

d.

Your baby is old enough to hold her own bottle, and this builds independence and self-esteem.

ANS: C

Feedback

A

Incorrect. Upon hearing the mother of a 6-month-old baby says that she gets her to go to sleep by giving her a bottle of milk to suck on until she falls asleep, the nurses best response would not be: You need to be watching your baby on a monitor or there the baby cannot see you.

B

Incorrect. Upon hearing the mother of a 6-month-old baby says that she gets her to go to sleep by giving her a bottle of milk to suck on until she falls asleep, the nurses best response would not be: Be sure you prop the bottle well and the babys head is slightly elevated.

C

Correct. Upon hearing the mother of a 6-month-old baby says that she gets her to go to sleep by giving her a bottle of milk to suck on until she falls asleep, the nurses best response would be: Letting a child fall asleep with a bottle of milk or other liquid containing sugar will cause cavities.

D

Incorrect. Upon hearing the mother of a 6-month-old baby says that she gets her to go to sleep by giving her a bottle of milk to suck on until she falls asleep, the nurses best response would not be: Your baby is old enough to hold her own bottle, and this builds independence and self-esteem.

PTS:1REF:p. 454 Developmental Assessment

OBJ: Cognitive Level: Application

10.In the health history interview, the nurse asks the caregivers if they give their 4-month-old baby honey. If the answer is yes, the nurse would do some teaching to:

a.

reinforce the caregivers for supplying this added source of immunity

b.

let the caregivers know that honey is helpful then the infant has vomiting and diarrhea

c.

inform the caregivers of the dangers of botulism from honey until the infant is 1 year old

d.

advise the caregivers not to give more than 4 ounces of honey per day

ANS: C

Feedback

A

Incorrect. Upon hearing the caregivers of a 4-month-old baby give her honey, the nurse would not do some teaching to reinforce the caregivers for supplying this added source of immunity.

B

Incorrect. Upon hearing the caregivers of a 4-month-old baby give her honey, the nurse would not do some teaching to let the caregivers know that honey is helpful then the infant has vomiting and diarrhea.

C

Correct. Upon hearing the caregivers of a 4-month-old baby give her honey, the nurse would do some teaching to inform the caregivers of the dangers of botulism from honey until the infant is 1 year old.

D

Incorrect. Upon hearing the caregivers of a 4-month-old baby give her honey, the nurse would never do some teaching to advise the caregivers not to give more than 4 ounces of honey per day.

PTS:1REF:p. 437 Nutritional Assessment

OBJ: Cognitive Level: Comprehension

11.A nurse is volunteering in a clinic in a developing country. The mother tells the nurse she is bottle-feeding with formula given to her by an earlier group of volunteers. The nurse will most want to check to be sure the mother has sufficient formula and that the formula contains:

a.

zinc

c.

sodium

b.

magnesium

d.

iron

ANS: D

Feedback

A

Incorrect. Upon hearing the mother in a developing country tell the nurse she is bottle-feeding with formula given to her by an earlier group of volunteers, the nurse will not most want to check to be sure that the formula contains zinc.

B

Incorrect. Upon hearing the mother in a developing country tell the nurse she is bottle-feeding with formula given to her by an earlier group of volunteers, the nurse will not most want to check to be sure that the formula contains magnesium.

C

Incorrect. Upon hearing the mother in a developing country tell the nurse she is bottle-feeding with formula given to her by an earlier group of volunteers, the nurse will not most want to check to be sure that the formula contains sodium.

D

Correct. Upon hearing the mother in a developing country tell the nurse she is bottle-feeding with formula given to her by an earlier group of volunteers, the nurse will most want to check to be sure the mother has sufficient formula and that the formula contains iron.

PTS:1REF:p. 436 Health History

OBJ: Cognitive Level: Application

12.The nurse asks the caregivers how many wet diapers their infant has in 24 hours. The nurse is comparing the wet diapers of this infant against the norm, which is the equivalent of:

a.

2 saturated diapers

c.

no less than 8 very wet diapers

b.

at least 6 very wet diapers

d.

10 or more saturated diapers

ANS: B

Feedback

A

Incorrect. Infants should have at least six very wet diapers every 24 hours, not 2 saturated diapers.

B

Correct. Infants should have at least six very wet diapers every 24 hours.

C

Incorrect. Infants should have at least six very wet diapers every 24 hours, not 8 very wet diapers.

D

Incorrect. Infants should have at least six very wet diapers every 24 hours, not 10 or more saturated diapers.

PTS:1REF:p. 436 Health History

OBJ: Cognitive Level: Comprehension

13.In teaching the caregivers about giving juice to their preschool-aged child, the nurse would advise the caregivers to give the child no more than how many ounces of juice per day?

a.

8-12

c.

18-24

b.

16

d.

28

ANS: A

Feedback

A

Correct. Limiting juice to no more than 8-12 ounces per day will help the child take more food at meals and snacks.

B

Incorrect. In teaching the caregivers about giving juice to their preschool-aged child, the nurse would not advise the caregivers to give the child 16 ounces of juice per day.

C

Incorrect. In teaching the caregivers about giving juice to their preschool-aged child, the nurse would not advise the caregivers to give the child 18-24 ounces of juice per day.

D

Incorrect. In teaching the caregivers about giving juice to their preschool-aged child, the nurse would not advise the caregivers to give the child 28 ounces of juice per day.

PTS:1REF:p. 436 Health History

OBJ: Cognitive Level: Comprehension

14.Children who are suspected of not having adequate calorie and protein intake might have which of the following laboratory tests ordered by their health care practitioner, which provide a picture of whether calorie or protein intake is sufficient or not?

a.

serum sodium and potassium

c.

arterial blood gases

b.

cerebral spinal fluid analysis

d.

serum albumin and prealbumin

ANS: D

Feedback

A

Incorrect. Suspecting inadequate calorie and protein intake, the health care practitioner will not order serum sodium and potassium testing.

B

Incorrect. Suspecting inadequate calorie and protein intake, the health care practitioner will not order testing cerebral spinal fluid analysis.

C

Incorrect. Suspecting inadequate calorie and protein intake, the health care practitioner will not order testing arterial blood gases.

D

Correct. Inadequate caloric intake is a nutritional problem. Two commonly ordered tests are serum albumin and prealbumin. Both tests reflect adequate calorie and protein intake.

PTS:1REF:p. 439 Nutritional Assessment

OBJ: Cognitive Level: Comprehension

15.The most reliable indicator of body fat is:

a.

skinfold thickness

c.

fit of clothing

b.

weight

d.

comparison with peers

ANS: A

Feedback

A

Correct. The most reliable indicator of body fat is skinfold thickness.

B

Incorrect. The most reliable indicator of body fat is not weight.

C

Incorrect. The most reliable indicator of body fat is not fit of clothing.

D

Incorrect. The most reliable indicator of body fat is not comparison with peers.

PTS: 1 REF: p. 439 Nutritional Assessment OBJ: Cognitive Level: Knowledge

16.The nurse administers the Denver Developmental Screening Test II to a child. The child fails to successfully complete a series of items. The nurse learns that the child has an infection, did not sleep well the night before, and is on antibiotics. Which of the following actions would be best on the part of the nurse?

a.

Do nothing, as the test results are not affected by the childs condition.

b.

Do not readminister the series that was failed or the entire test, as retakes are invalid.

c.

Administer the test again in 1 month if the child is then well and sleeping well.

d.

Wait at least 2 years to administer the test, moving up to the Denver III.

ANS: C

Feedback

A

Incorrect. In the event the child fails to successfully complete a series of items of the Denver Developmental Screening Test II, the nurse will not choose to do nothing, as the test results can be very much affected by the childs condition.

B

Incorrect. In the event the child fails to successfully complete a series of items of the Denver Developmental Screening Test II, the nurse will readminister the test, retakes are valid.

C

Correct. In the event the child fails to successfully complete a series of items of the Denver Developmental Screening Test II, the nurse will choose to administer the test again in 1 month if the child is then well and sleeping well.

D

Incorrect. In the event the child fails to successfully complete a series of items of the Denver Developmental Screening Test II, the nurse will not choose to wait at least 2 years to administer the test. The purpose of the test is to identify developmental disability early. There is not Denver III.

PTS:1REF:p. 440 Developmental Assessment

OBJ: Cognitive Level: Application

17.The pediatric nurse practitioner has a small toy hooked onto the stethoscope and is observed to be humming at times during the physical examination of a child. The reason for the toy and humming is most likely:

a.

to provide a distraction to increase cooperativeness

b.

to entertain and keep the nurse in a good mood to work with children

c.

something that has little to do with the examination of the child

d.

to keep the child focused so he or she wont get into things in the exam room

ANS: A

Feedback

A

Correct. The use of game playing and distraction will increase child cooperativeness during physical assessment.

B

Incorrect. The use of a small toy hooked onto the stethoscope and humming is not meant to entertain and keep the nurse in a good mood to work with children.

C

Incorrect. The use of a small toy hooked onto the stethoscope and humming is not something that has little to do with the examination of the child, it can help a lot.

D

Incorrect. The use of a small toy hooked onto the stethoscope and humming is not something that is intended to keep the child focused so he or she wont get into things in the exam room.

PTS:1REF:p. 442 Developmental Assessment

OBJ: Cognitive Level: Application

18.Which of the following types of lighting would be best for the nurse to use during the pediatric physical assessment?

a.

fluorescent

c.

yellow

b.

halogen

d.

natural

ANS: D

Feedback

A

Incorrect. Fluorescent lighting would not be best for the nurse to use during the pediatric physical assessment.

B

Incorrect. Halogen lighting would not be best for the nurse to use during the pediatric physical assessment.

C

Incorrect. Yellow lighting would not be best for the nurse to use during the pediatric physical assessment.

D

Correct. Use natural lighting, if available. Fluorescent lighting makes assessing varying degrees of cyanosis and jaundice difficult.

PTS:1REF:p. 443 Developmental Assessment

OBJ: Cognitive Level: Comprehension

19.The nurse will perform all invasive or uncomfortable procedures such as ear inspection at what point during the physical examination?

a.

in a sequential manner

c.

last

b.

first

d.

optional

ANS: C

Feedback

A

Incorrect. The nurse will not perform all invasive or uncomfortable procedures in a sequential manner.

B

Incorrect. The nurse will not perform all invasive or uncomfortable procedures first.

C

Correct. Perform all invasive or uncomfortable procedures (ear inspection, hip palpation) last because they may cause discomfort, crying, fear and increased heart rate.

D

Incorrect. The nurse will not perform all invasive or uncomfortable procedures optionally.

PTS:1REF:p. 443 Developmental Assessment

OBJ: Cognitive Level: Comprehension

20.At what age are children old enough to have their temperature taken orally?

a.

10 months

c.

3 years

b.

18 months

d.

5 to 6 years or more

ANS: D

Feedback

A

Incorrect. Children are not old enough to have their temperature taken orally at 10 months of age.

B

Incorrect. Children are not old enough to have their temperature taken orally at 18 months of age.

C

Incorrect. Children are not old enough to have their temperature taken orally at 3 years of age.

D

Correct. The oral route is convenient and accessible, but an accurate measurement is difficult to obtain in most toddlers and preschoolers. Therefore, the oral route is reserved for children ages 5 to 6 years or older.

PTS:1REF:p. 442 Developmental Assessment

OBJ: Cognitive Level: Comprehension

21.Which of the following methods of taking the temperature of a child is considered to be most accurate?

a.

oral

c.

axillary

b.

rectal

d.

tympanic

ANS: B

Feedback

A

Incorrect. An oral temperature is not considered the most accurate.

B

Correct. A rectal temperature is considered the most accurate and can be taken in children of all ages.

C

Incorrect. An axillary temperature is not considered the most accurate.

D

Incorrect. A tympanic temperature is not considered the most accurate.

PTS:1REF:p. 442 Developmental Assessment

OBJ: Cognitive Level: Comprehension

22.The nurse is ready to take the temperature of a child who is to be discharged from the hospital if the temperature is within the normal range. The health care practitioner and family are waiting to hear about the temperature. The nurse considers taking an axillary temperature but decides instead to take the temperature orally. What is the most likely reason that the nurse decided to take the temperature orally in this case?

a.

The axilla is not sensitive to early temperature changes, and accuracy was critical in this case.

b.

An oral temperature is much quicker to determine than an axillary temperature.

c.

Locating an axillary thermometer might be more difficult than finding an oral one.

d.

The oral temperature reading is easier and safer to get then compared to an axillary temperature.

ANS: A

Feedback

A

Correct. An axillary temperature is safe, noninvasive, and can be taken in all age groups. This route may be contraindicated then accuracy is especially critical.

B

Incorrect. The choice of taking an oral temperature is based upon accuracy not speed.

C

Incorrect. The choice of taking an oral temperature is based upon accuracy not the ease of locating an appropriate thermometer.

D

Incorrect. The choice of taking an oral temperature is based upon accuracy not the ease of reading or a choice of safety.

PTS:1REF:p. 442 Developmental Assessment

OBJ: Cognitive Level: Application

23.The nurse takes the temperature of a newborn and gets a reading of 37.7 degrees C (99.6 degrees F). The nurse interprets this temperature as:

a.

very high for a newborn and calls the health care practitioner

b.

high for an infant of this age and decides to retake it in 20 minutes

c.

normal and proceeds to chart the temperature in the infants record

d.

below normal and adds a warmed blanket to the infants crib

ANS: C

Feedback

A

Incorrect. Taking the temperature of a newborn, the nurse gets a reading of 37.7 degrees C (99.6 degrees F). The nurse does not interpret this temperature as very high for a newborn and does not call the health care practitioner.

B

Incorrect. Taking the temperature of a newborn, the nurse gets a reading of 37.7 degrees C (99.6 degrees F). The nurse does not interpret this temperature as high for an infant of this age and does not decide to retake it in 20 minutes.

C

Correct. Taking the temperature of a newborn, the nurse gets a reading of 37.7 degrees C (99.6 degrees F). The nurse interprets this temperature as normal and proceeds to chart the temperature in the infants record.

D

Incorrect. Taking the temperature of a newborn, the nurse gets a reading of 37.7 degrees C (99.6 degrees F). The nurse does not interpret this temperature as below normal and does not add a warmed blanket to the infants crib.

PTS:1REF:p. 442 Developmental Assessment

OBJ: Cognitive Level: Comprehension

24.The nurse is preparing to count the respirations of an infant. The nurse will count the respirations for:

a.

15 seconds, watching the chest

c.

1 minute, watching the chest

b.

30 seconds, watching the abdomen

d.

1 minute, watching the abdomen

ANS: D

Feedback

A

Incorrect. The nurse will not count the respirations for 15 seconds, watching the chest of an infant.

B

Incorrect. The nurse will not count the respirations for 30 seconds, watching the abdomen, but count for one minute.

C

Incorrect. The nurse will not count the respirations for 1 minute, watching the chest in an infant.

D

Correct. The nurse counts the number of respirations per minute early in the assessment then the child is most cooperative and not crying, remembering for infants and toddlers to observe the expansion of the abdomen.

PTS:1REF:p. 444 Developmental Assessment

OBJ: Cognitive Level: Comprehension

25.The nurse on the pediatric unit is assigned to care for four children. One of the children is 18 months old and the rest are 3, 4, and 4-1/2 years old. The youngest is in for observation, the 3-year-old has a cardiac problem, and the two older children are in for tests. After a report the nurse takes the childrens vital signs. The nurse would need to take the pulses in which of the following ways?

a.

radial pulse on all the children

b.

radial on the two older children and apical on the 18-month-old and the child with a cardiac problem

c.

apical on all children under 5

d.

apical only on the child with a cardiac problem

ANS: B

Feedback

A

Incorrect. A radial pulse can be obtained on children over 2 years of age, but not the 18 month old nor the child with a cardiac problem.

B

Correct. An apical pulse should be taken on neonates, infants and young children (under 2 years of age) and on all children with cardiac problems or on digitalis preparations.

C

Incorrect. An apical pulse should be taken on all children under 2 years of age, not 5.

D

Incorrect. Apical pulse should be taken on the child under 2 years of age and the child with a cardiac problem.

PTS:1REF:p. 444 Developmental Assessment

OBJ: Cognitive Level: Application

26.The nurse would expect to find which of the following resting respiratory rates in the normal newborn?

a.

40

c.

20

b.

30

d.

15

ANS: A

Feedback

A

Correct. The nurse will expect a resting respiratory rates in the normal newborn to average 40.

B

Incorrect. The nurse will expect a resting respiratory rates in the normal newborn to average 40, in a range of 30 to 50.

C

Incorrect. The nurse will expect a resting respiratory rates in the normal newborn to average much higher than 20.

D

Incorrect. The nurse will expect a resting respiratory rates in the normal newborn to average much higher than 15.

PTS:1REF:p. 444 Developmental Assessment

OBJ: Cognitive Level: Comprehension

27.A caregiver asks the nurse to explain his infants weight loss of 10% of birth weight, which occurred by the third or fourth day after birth. The nurse would explain that this weight loss is known as physiological weight loss and is due to which of the following causes?

a.

not being nourished any longer by the rich placenta

b.

the exhaustion of the baby after the birth experience

c.

the loss of extracellular fluid and meconium

d.

the time it takes to learn to suckle adequately

ANS: C

Feedback

A

Incorrect. Explaining the infants weight loss of 10% of birth weight to the caregiver, the nurse will not offer as explanation that the infant is not being nourished any longer by the rich placenta.

B

Incorrect. Explaining the infants weight loss of 10% of birth weight to the caregiver, the nurse will not offer as explanation the exhaustion of the baby after the birth experience.

C

Correct. Usually, neonates lose approximately 10% of birth weight by the third or fourth day after birth. This expected change in weight is called physiological weight loss, and it is due to the loss of extracellular fluid and meconium.

D

Incorrect. Explaining the infants weight loss of 10% of birth weight to the caregiver, the nurse will not offer as explanation the time it takes to learn to suckle adequately.

PTS:1REF:p. 446 Developmental Assessment

OBJ: Cognitive Level: Comprehension

28.Head circumference is measured in children with known or suspected hydrocephalus and children less than how many months old?

a.

40

c.

32

b.

36

d.

24

ANS: D

Feedback

A

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 40.

B

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 36.

C

Incorrect. Head circumference is no longer measured in children after they are 24 months old, not 32.

D

Correct. Head circumference is measured in children with known or suspected hydrocephalus and children less than 24 months old.

PTS:1REF:p. 446 Developmental Assessment

OBJ: Cognitive Level: Comprehension

29.A childs height must fall in what percentile range to be considered normal enough not to warrant further investigation?

a.

5% -95%

c.

20%-80%

b.

10%-90%

d.

25%-75%

ANS: A

Feedback

A

Correct. A height below the 5th or above the 95th percentile warrants investigation.

B

Incorrect. A height below the 10th or above the 90th percentile does not warrant investigation.

C

Incorrect. A height below the 20th or above the 80th percentile does not warrant investigation.

D

Incorrect. A height below the 25th or above the 75th percentile does not warrant investigation.

PTS:1REF:p. 446 Developmental Assessment

OBJ: Cognitive Level: Comprehension

30.The mother of a 9-month-old infant is concerned that the head circumference of her baby is greater than the chest circumference. The best response by the nurse is:

a.

This is normal until the age of 1 year, and then the chest will be greater.

b.

Perhaps your baby was small for gestational age or premature.

c.

Let me ask you a few questions, and perhaps we can figure out the cause of this difference.

d.

These circumferences normally are the same, but in some babies this just differs.

ANS: A

Feedback

A

Correct. From birth to about 1 year, the head circumference is greater than the chest circumference.

B

Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: Perhaps your baby was small for gestational age or premature.

C

Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: Let me ask you a few questions, and perhaps we can figure out the cause of this difference.

D

Incorrect. In response to the expressed concern by the mother of a 9-month-old infant that the head circumference of her baby is greater than the chest circumference, the best response by the nurse is not: These circumferences normally are the same, but in some babies this just differs.

PTS:1REF:p. 447 Developmental Assessment

OBJ: Cognitive Level: Application

31.The nurse is assessing a newborn for jaundice. The nurse knows that jaundice is easiest to detect in the newborn in certain areas. Because of this knowledge, the nurse will assess which of the following?

a.

the scapula, under the arm, and in the groin

b.

under the chin and under the knee

c.

under the scrotum or inside the labia

d.

on the tip of nose, external ear, lips, hands, and feet

ANS: D

Feedback

A

Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin of the scapula, under the arm, and in the groin.

B

Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin under the chin and under the knee.

C

Incorrect. In assessing a newborn for jaundice, the nurse will not focus on skin under the scrotum or inside the labia.

D

Correct. Observe the color of the skin, especially at the tip of the nose, the external ear, the lips, the hands, and the feet. These areas are prominent locations for detecting cyanosis or jaundice.

PTS:1REF:p. 447 Developmental Assessment

OBJ: Cognitive Level: Comprehension

32.The nurse notices that a 6-month-old infant born to Latino caregivers has deep-blue, almost black coloration over the lumbar and sacral areas of the spine and the buttocks. The nurses first guess in looking for causes would be:

a.

child abuse

c.

lack of bathing

b.

ritual painting

d.

Mongolian spots

ANS: D

Feedback

A

Incorrect. Observing deep-blue, almost black coloration over the lumbar and sacral areas of the spine and the buttocks of a Latino infant, the nurse should not assume child abuse.

B

Incorrect. Observing deep-blue, almost black coloration over the lumbar and sacral areas of the spine and the buttocks of a Latino infant, the nurse should not assume ritual painting.

C

Incorrect. Observing deep-blue, almost black coloration over the lumbar and sacral areas of the spine and the buttocks of a Latino infant, the nurse should not assume lack of bathing.

D

Correct. Mongolian spots, a deep-blue pigmentation over the lumbar and sacral areas of the spine, buttocks, upper back or shoulders in newborns of African, Latino, or Asian descent, are extremely common and not to be confused with ecchymosis or signs of child abuse.

PTS:1REF:p. 448 Developmental Assessment

OBJ: Cognitive Level: Comprehension

33.The caregivers notice that the baby has a dark-black tuft of hair and a dimple over the lumbosacral area. This occurrence is:

a.

normal and common

b.

normal and rare

c.

abnormal and may indicate spina bifida occulta

d.

abnormal and may indicate cancer

ANS: C

Feedback

A

Incorrect. The presence of a dark-black tuft of hair and a dimple over the lumbosacral area is not normal and common.

B

Incorrect. The presence of a dark-black tuft of hair and a dimple over the lumbosacral area is not normal and rare.

C

Correct. A dark-black tuft of hair or a dimple over the lumbosacral area is abnormal and may indicate that the neonate has a vertebral defect known as spina bifida occulta.

D

Incorrect. The presence of a dark-black tuft of hair and a dimple over the lumbosacral area is abnormal but does not indicate cancer.

PTS:1REF:p. 448 Developmental Assessment

OBJ: Cognitive Level: Comprehension

34.Atopic dermatitis (AD) is a skin lesion that is:

a.

due to an allergy to the mother or father

b.

common and involves the epidermis and superficial dermis

c.

rarely seen outside the tropical climates

d.

seen only in children over age 4

ANS: B

Feedback

A

Incorrect. Atopic dermatitis (AD) is a skin lesion that is not due to an allergy to the mother or father.

B

Correct. Eczema or atopic dermatitis (AD) is a common skin disorder involving inflammation of the epidermis and superficial dermis. The lesions of AD are usually symmetrical, scaly, erythematous patches or plaques with possible exudation and crusting.

C

Incorrect. Atopic dermatitis (AD) is a skin lesion that is seen in all climates.

D

Incorrect. Atopic dermatitis (AD) is a skin lesion that is seen in all ages.

PTS:1REF:p. 448 Developmental Assessment

OBJ: Cognitive Level: Comprehension

35.A thick, cheesy, protective deposit of sebum and shed epithelial cells on the surface of the skin is referred to as:

a.

sebum epithelium

c.

vernix caseosa

b.

epitheliosis

d.

the third skin

ANS: C

Feedback

A

Incorrect. Sebum epithelium is the oily secretion normally on the skin.

B

Incorrect. Epitheliosis is not in the medical dictionary.

C

Correct. Newborns may have vernix caseosa, a thick, cheesy, protective deposit of sebum and shed epithelial cells.

D

Incorrect. The third skin is not in the medical dictionary.

PTS:1REF:p. 448 Developmental Assessment

OBJ: Cognitive Level: Comprehension

36.While assessing a child, the nurse pinches up a small section of the childs skin between the thumb and forefinger, and then quickly releases it. The nurse is assessing for:

a.

hydration

c.

excess fat

b.

skin tension

d.

pain tracks

ANS: A

Feedback

A

Correct. Skin turgor or elasticity reflects the childs state of hydration. It is assessed by pinching a small section of the childs skin between your thumb and forefinger and quickly releasing it.

B

Incorrect. The nurse is not assessing for skin tension.

C

Incorrect. The nurse is not assessing for excess fat.

D

Incorrect. The nurse is not assessing for pain tracks.

PTS:1REF:p. 448 Developmental Assessment

OBJ: Cognitive Level: Comprehension

37.The nurse is assessing an 8-month-old infant for head lag, pulling the infant by the hands from a supine to a sitting position. The head does not stay in line with the body then being pulled forward. Which of the following statements best represents the significance of this finding?

a.

This is a normal finding, as the infants head will not stay in line until after 8 months of age.

b.

The nurse has not conducted the test correctly and must do it again using proper technique.

c.

Significant head lag after the age of 6 months may indicate brain injury and needs further investigations.

d.

Head lag should not be tested until the child is over 1 year of age.

ANS: C

Feedback

A

Incorrect. Since the head does not stay in line with the body then being pulled forward into a sitting position, the nurse assesses that this is not normal.

B

Incorrect. Pulling the infant by the hands from a supine to a sitting position is the correct means to test for head lag.

C

Correct. Significant head lag indicates head control is not keeping pace with normal development, and after 6 months of age may indicate brain injury and should be further investigated.

D

Incorrect. Testing for head lag should begin as early as 3 months, no later than 4 months.

PTS:1REF:p. 449 Developmental Assessment

OBJ: Cognitive Level: Application

38.While working in a public health clinic, the nurse assesses a child who is 3 years old. The nurse finds an open and wide anterior fontanel. The nurse is aware that an open anterior fontanel at this age most likely is:

a.

normal

c.

due to disease, such as rickets

b.

a result of prolonged dehydration

d.

due to a congenital disorder

ANS: C

Feedback

A

Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not normal.

B

Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not the result of prolonged dehydration, but a sunken depressed fontanel points to improper hydration.

C

Correct. A wide anterior fontanel in a child older than 2 1/2 years is an abnormal finding. An anterior fontanel that remains open after 2 1/2 years of age may indicate disease such as rickets.

D

Incorrect. The finding of an open and wide anterior fontanel in a 3 year old child is not due to a congenital disorder.

PTS:1REF:p. 449 Developmental Assessment

OBJ: Cognitive Level: Comprehension

39.While palpating the fontanels of a 1-month-old infant, the nurse finds the posterior fontanel to be 2 to 3 cm. The nurse is aware that this finding occurs with which of the following conditions or disorders?

a.

diabetes

c.

cerebral palsy

b.

premature birth

d.

congenital hypothyroidism

ANS: D

Feedback

A

Incorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur with diabetes.

B

Incorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur with premature birth.

C

Incorrect. A posterior fontanel greater than 1.5 cm in diameter is abnormal but does not occur with cerebral palsy.

D

Correct. A posterior fontanel greater than 1.5 cm in diameter is abnormal and occurs with congenital hypothyroidism.

PTS:1REF:p. 449 Developmental Assessment

OBJ: Cognitive Level: Comprehension

40.Which of the following best defines craniosynostosis?

a.

premature ossification of suture lines resulting in early fusion of the bones of the skull

b.

sinus openings into the cranium allowing for changes in intracranial pressure

c.

wider spaces than normal between the bones of the cranium

d.

changes in the size and shape of the skull due to the absence of lymph and sinus openings

ANS: A

Feedback

A

Correct. Craniosynostosis is premature ossification of suture lines, thereby there is early formation and fusion of skull bones. Craniosynostosis may be caused by metabolic disorders or may be a secondary consequence of Microcephaly.

B

Incorrect. Craniosynostosis is not defined as sinus openings into the cranium allowing for changes in intracranial pressure.

C

Incorrect. Craniosynostosis is not defined as wider spaces than normal between the bones of the cranium.

D

Incorrect. Craniosynostosis is not defined as changes in the size and shape of the skull due to the absence of lymph and sinus openings.

PTS:1REF:p. 449 Developmental Assessment

OBJ: Cognitive Level: Comprehension

41.While palpating the outer layer of the cranial bones behind and above the ears, the nurse finds a softening of this area and has the sensation of pressing on a table-tennis ball then palpating the area. The nurse knows this finding is indicative of:

a.

shaken baby syndrome

c.

craniotabes

b.

skull fracture

d.

crepitus

ANS: C

Feedback

A

Incorrect. The findings of a softening of the cranial bones behind and above the ears is not associated with shaken baby syndrome.

B

Incorrect. The findings of a softening of the cranial bones behind and above the ears is not associated with a skull fracture.

C

Correct. A softening of the outer layer of cranial bones behind and above the ears combined with a ping-pong ball sensation as the area is pressed in gently with the fingers is indicative of craniotabes, an abnormal finding. Craniotabes is associated with rickets, syphilis, hydrocephaly, or hypervitaminosis.

D

Incorrect. The findings of a softening of the cranial bones behind and above the ears is not associated with crepitus (flatulence).

PTS:1REF:p. 449 Developmental Assessment

OBJ: Cognitive Level: Comprehension

42.The caregivers notice a swelling over the cranial bones of their newborn. The nurse examines the baby and tells the caregivers that this appears to be a cephalhematoma and will disappear with time. The nurse is reasonably certain this is a cephalhematoma and not some other abnormality because the:

a.

mother had a forceps delivery

c.

color is the same as a cephalhematoma

b.

swelling does not cross suture lines

d.

swelling is over a large area of the head

ANS: B

Feedback

A

Incorrect. The means of delivery may or may not involve a cephalhematoma, but would not be the only possibility.

B

Correct. Another abnormal finding in a newborn is a cephalhematoma, a localized, subcutaneous swelling over one of the cranial bones. The swelling does not cross suture lines.

C

Incorrect. Cephalhematoma swelling does not present a differing color.

D

Incorrect. Cephalhematoma swelling is localized, not swelling over a large area of the head.

PTS:1REF:p. 450 Developmental Assessment

OBJ: Cognitive Level: Comprehension

43.Swelling over the occipitoparietal region of the skull is called by which of the following terms?

a.

occipitocapus

c.

edematous capitus

b.

caput succedaneum

d.

parietus sepitus

ANS: B

Feedback

A

Incorrect. Swelling over the occipitoparietal region of the skull is not called occipitocapus.

B

Correct. Another variation in the newborn that causes the shape of the skull to look markedly asymmetric is caput succedaneum or swelling over the occipitoparietal region of the skull.

C

Incorrect. Swelling over the occipitoparietal region of the skull is not called edematous capitus.

D

Incorrect. Swelling over the occipitoparietal region of the skull is not called parietus sepitus.

PTS:1REF:p. 450 Developmental Assessment

OBJ: Cognitive Level: Comprehension

44.When the nurse is doing vision screenings on young children, which of the following tests would be used on a child who is 6 years old and able to read the alphabet?

a.

finger point

c.

Snellen E

b.

Snellen X

d.

adult Snellen

ANS: D

Feedback

A

Incorrect. When the nurse is doing vision screenings on young children aged 6 and able to read the alphabet, she would not use the finger point.

B

Incorrect. When the nurse is doing vision screenings on young children aged 6 and able to read the alphabet, she would not use the Snellen X (no such test exists).

C

Incorrect. When the nurse is doing vision screenings on young children aged 6 and able to read the alphabet, she would not use the Snellen E test (used for children aged 3 or any child unable to read the alphabet).

D

Correct. The adult Snellen chart can be used on children as young as 6 years, provided they are able to read the alphabet.

PTS:1REF:p. 450 Developmental Assessment

OBJ: Cognitive Level: Comprehension

45.The nurse doing vision screenings on 3- to 4-year-old children would refer a child to the ophthalmologist if both eyes score less than 15/30 or scores for the childs right and left eye differ by how many feet?

a.

1

c.

3

b.

2

d.

5

ANS: D

Feedback

A

Incorrect. Vision screenings on 3- to 4-year-old children that produce scores lower than 15/30 or a 5 feet difference between eyes suggest referral, not a 1 foot difference.

B

Incorrect. Vision screenings on 3- to 4-year-old children that produce scores lower than 15/30 or a 5 foot difference between eyes suggest referral, not a 2 foot difference.

C

Incorrect. Vision screenings on 3- to 4-year-old children that produce scores lower than 15/30 or a 5 foot difference between eyes suggest referral, not a 3 foot difference.

D

Correct. Three-to-4-year-old children should be able to achieve a score of 15/30 to 20/30 on the Allen test. Each eye should have the same score. If the score for the childs right and left eyes differ by 5 feet or more or either or both eyes score less than 15/30, refer the child to the ophthalmologist.

PTS:1REF:p. 450 Developmental Assessment

OBJ: Cognitive Level: Comprehension

46.The nurse using the Hirschberg test would expect to find which of the following in a child with normal eyes?

a.

the light reflected symmetrically in the center of both corneas

b.

the light reflecting red on the optic nerve

c.

arteries and veins in the proper proportion

d.

no evidence of retinal detachment

ANS: A

Feedback

A

Correct. The nurse using the Hirschberg test would expect to find the light reflected symmetrically in the center of both corneas in a child with normal eyes.

B

Incorrect. The nurse using the Hirschberg test would not expect to find the light reflecting red on the optic nerve.

C

Incorrect. The nurse using the Hirschberg test would not be checking for arteries and veins in the proper proportion.

D

Incorrect. The nurse using the Hirschberg test would not be checking for retinal detachment.

PTS:1REF:p. 451 Developmental Assessment

OBJ: Cognitive Level: Comprehension

47.Which of the following statements best describes dacryocystitis?

a.

a bladder infection brought about by wearing Dacron fabrics

b.

an infection of the lacrimal sac caused by the obstruction of the lacrimal duct

c.

repeated bladder infections that are resistant to antibiotics

d.

eye infection secondary to a bladder infection

ANS: B

Feedback

A

Incorrect. Dacryocystitis is not a bladder infection brought about by wearing Dacron fabrics.

B

Correct. Dacryocystitis is an infection of the lacrimal sac caused by obstruction of the lacrimal duct. It is characterized by tearing and discharges from the eye.

C

Incorrect. Dacryocystitis is not a repeated bladder infection that are resistant to antibiotics.

D

Incorrect. Dacryocystitis is not an eye infection secondary to a bladder infection.

PTS:1REF:p. 451 Developmental Assessment

OBJ: Cognitive Level: Comprehension

48.In inspecting the eyes of a child, the nurse notes that there are some small white flecks around the perimeter of the iris. These white flecks are called:

a.

cotton patches

c.

snow spots

b.

Brushfield spots

d.

northern lights

ANS: B

Feedback

A

Incorrect. Small white flecks around the perimeter of the iris are not called cotton patches.

B

Correct. Small white flecks around the perimeter of the iris, called Brushfield spots, are abnormal and indicative of the child with Down syndrome.

C

Incorrect. Small white flecks around the perimeter of the iris are not called snow spots.

D

Incorrect. Small white flecks around the perimeter of the iris are not called northern lights.

PTS:1REF:p. 451 Developmental Assessment

OBJ: Cognitive Level: Comprehension

49.White flecks around the perimeter of the iris in children are:

a.

normally found in 40% of children

b.

found in a child with Down syndrome

c.

seen in children with congenital cataracts

d.

observed in children with retinal detachment

ANS: B

Feedback

A

Incorrect. White flecks around the perimeter of the iris in children are not normally found in 40% of children.

B

Correct. White flecks around the perimeter of the iris in children are found in a child with Down syndrome.

C

Incorrect. White flecks around the perimeter of the iris in children are not seen in children with congenital cataracts.

D

Incorrect. White flecks around the perimeter of the iris in children are not observed in children with retinal detachment.

PTS:1REF:p. 451 Developmental Assessment

OBJ: Cognitive Level: Comprehension

50.The optical blink reflex occurs then the newborns pupil reaction to light is assessed and a newborn blinks and:

a.

flexes the head closer to the body

c.

arches the back

b.

extends the chin away from the body

d.

throws up the hands in the air

ANS: A

Feedback

A

Correct. The optical blink reflex occurs then the newborns pupil reaction to light is assessed and a newborn blinks and flexes the head closer to the body.

B

Incorrect. The newborns optical blink reflex does not involve extending the chin away from the body.

C

Incorrect. The newborns optical blink reflex does not involve arching of the back.

D

Incorrect. The newborns optical blink reflex does not involve the hands.

PTS:1REF:p. 452 Developmental Assessment

OBJ: Cognitive Level: Comprehension

51.The nurse inspects a childs red reflex with an ophthalmoscope and finds black spots or opacities within the red reflex. The nurse knows these findings:

a.

are normal in 95% of children

b.

indicate congenital permanent blindness

c.

suggest the child has experienced trauma

d.

are abnormal and may indicate a cataract

ANS: D

Feedback

A

Incorrect. Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows these findings are abnormal.

B

Incorrect. Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows these findings do not indicate congenital permanent blindness.

C

Incorrect. Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows these findings do not suggest the child has experienced trauma.

D

Correct. Inspecting a childs red reflex with an ophthalmoscope and finding black spots or opacities, the nurse knows these findings are abnormal and may indicate a cataract.

PTS:1REF:p. 452 Developmental Assessment

OBJ: Cognitive Level: Comprehension

52.If the nurse finds a yellowish or white light reflex (cats eye reflex) then inspecting the retina, he or she knows this may indicate:

a.

retinoblastoma

c.

retrolental fibroplasia

b.

albino characteristics

d.

retinitis pigmentosa

ANS: A

Feedback

A

Correct. If the nurse finds a yellowish or white light reflex (cats eye reflex) then inspecting the retina, he or she knows this may indicate retinoblastoma. This is abnormal and may indicate a malignant glioma located in the posterior chamber of the eye.

B

Incorrect. If the nurse finds a yellowish or white light reflex (cats eye reflex) then inspecting the retina, he or she knows this does not indicate albino characteristics.

C

Incorrect. If the nurse finds a yellowish or white light reflex (cats eye reflex) then inspecting the retina, he or she knows this does not indicate retrolental fibroplasia.

D

Incorrect. If the nurse finds a yellowish or white light reflex (cats eye reflex) then inspecting the retina, he or she knows this does not indicate retinitis pigmentosa.

PTS:1REF:p. 452 Developmental Assessment

OBJ: Cognitive Level: Comprehension

53.The nurse inspecting the optic disc of a child with intracranial hemorrhage would find:

a.

the disc to be edematous and larger than usual

b.

the margins of the optic disc to be poorly defined (blurred)

c.

a small-sized disc

d.

the color of the disc to be bright red and darker than usual

ANS: B

Feedback

A

Incorrect. The nurse inspecting the optic disc of a child with intracranial hemorrhage would not find the disc to be edematous and larger than usual.

B

Correct. The nurse inspecting the optic disc of a child with intracranial hemorrhage would find the margins of the optic disc to be poorly defined (blurred).

C

Incorrect. The nurse inspecting the optic disc of a child with intracranial hemorrhage would not find a small-sized disc.

D

Incorrect. The nurse inspecting the optic disc of a child with intracranial hemorrhage would not find the color of the disc to be bright red and darker than usual.

PTS:1REF:p. 452 Developmental Assessment

OBJ: Cognitive Level: Comprehension

54.To assess the pinna position of the ears of a child, the nurse would draw an imaginary line from the outer canthus to the top of the ear. If the nurse finds that the ears are below the imaginary line, this means that:

a.

the child is prone to heart problems and may have cardiac anomalies

b.

the finding is abnormal and may be a sign of renal anomalies or Down syndrome

c.

the child has inherited low-set ears that may run in the family of one or more parents

d.

the child is prone to deafness and must be checked for hearing very carefully at intervals

ANS: B

Feedback

A

Incorrect. If the nurse finds that the ears are below the imaginary line, this does not mean that the child is prone to heart problems and may have cardiac anomalies.

B

Correct. In assessing the pinna position of the ears of a child, the nurse would draw an imaginary line from the outer canthus to the top of the ear, and expect that the top of the ear should be at or slightly above the imaginary line. If the nurse finds that the ears are below the imaginary line, the finding is abnormal and may be a sign of renal anomalies or Down syndrome.

C

Incorrect. If the nurse finds that the ears are below the imaginary line, this does not mean that the child has inherited low-set ears that may run in the family of one or more parents.

D

Incorrect. If the nurse finds that the ears are below the imaginary line, this does not mean that the child is prone to deafness and must be checked for hearing very carefully at intervals.

PTS:1REF:p. 452 Developmental Assessment

OBJ: Cognitive Level: Comprehension

55.To look into the ear of a child younger than 3 years old, the nurse would position the ear by pulling the auricle:

a.

down and out

c.

in and forward

b.

back and up

d.

in and backward

ANS: A

Feedback

A

Correct. For the child up to age 3, the nurse should pull the lower auricle down and out to straighten the canal.

B

Incorrect. It would not be appropriate to position the ear by pulling back and up.

C

Incorrect. It would not be appropriate to position the ear by pulling in and forward.

D

Incorrect. It would not be appropriate to position the ear by pulling in and backward.

PTS:1REF:p. 453 Developmental Assessment

OBJ: Cognitive Level: Comprehension

56.Patency of the nares must be determined at birth because:

a.

of the possibility of polyps

b.

mouth breathing will exhaust the newborn

c.

the baby will have nasal flaring if not patent

d.

newborns are nose breathers

ANS: D

Feedback

A

Incorrect. The evaluation of patency is not indicated because of the possibility of polyps.

B

Incorrect. The evaluation of patency is not indicated because of the possibility of mouth breathing.

C

Incorrect. The evaluation of patency is not indicated because of the possibility of the potential for nasal flaring.

D

Correct. The patency of the nares must be determined at birth because the newborn is an obligatory nose breather.

PTS:1REF:p. 453 Developmental Assessment

OBJ: Cognitive Level: Application

MULTIPLE RESPONSE

1.The most common causes of clubfoot include which of the following? Select all that apply.

a.

abnormal intrauterine position of the fetal foot

b.

maternal infection during the first trimester

c.

genetics

d.

lack of prenatal vitamins, especially in the first trimester

ANS: A, C

Feedback

Correct

Metatarsal varus (clubfoot) is characterized by medially adducted and inverted toes and forefoot. Clubfoot typically results from an abnormal intrauterine position of the fetal foot.

Metatarsal varus (clubfoot) is characterized by medially adducted and inverted toes and forefoot. Clubfoot typically results from an abnormal intrauterine position of the fetal foot, although heredity may also play a role in the etiology.

Incorrect

Clubfoot is not associated with maternal infection during the first trimester.

Clubfoot is not associated with a lack of prenatal vitamins during the first trimester.

PTS:1REF:p. 461 Developmental Assessment

OBJ: Cognitive Level: Application

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