PEDIATRIC ASSESSMENT 1

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A nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first? *

1 point

A. A two day old who is lying quietly alert with a heart rate of 185

B. A one day old who is crying and has a bulging anterior fontanelle

C. A 12-hour-old who is being held, with respirations that are 45 breaths per minute and irregular

D. A five hour old who is sleeping and whose hands and feet are blue bilaterally

Q2. The nurse performs a newborn assessment. Which finding does the nurse report to the health care provider? *

1 point

1.The outer canthus of the eye is higher than the upper tip of the pinna of the ear.

2.Swelling of the tissue over the occipital area that crosses the suture line.

3.The anterior fontanelle is flat with the contour of the skull when palpate.

4.The head circumference is 1 cm greater than the chest circumference.

Q3. You are taking care of an infant newly diagnosed with hydrocephalus. Which of the following assessment findings do you expect?
Select all that apply.
*

1 point

A. Increased head circumference

B. Macewen’s sign

C. Sunken anterior fontanelle

D. Setting sun eyes

Required

Q4. Which of the following statements is true regarding growth during the infancy period?
Select all that apply.

*

1 point

A. Birth weight doubles by 4 months of age.

B. The posterior fontanelle should be soft and flat at 3 months of age.

C. The anterior fontanelle closes between 1 and 2 months of age.

D. Birth weight triples by 12 months of age.

Required

Q5. The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the
mother that it is helpful to introduce solid foods into the infant’s diet at age:
*

1 point

■ 1. 1 to 2 months.

■ 2. 5 to 6 months.

■ 3. 8 to 10 months.

■ 4. 10 to 12 months

Q6. While performing an initial physical assessment on a client who was brought in following a motor vehicle accident, the nurse notes that the client is exhibiting decerebrate posturing. Which best describes this posture? *

1 point

A. Legs and feet extended, arms pulled up and tucked into chest

B. Legs and feet flaccid, arms rigid and flexed at the elbows

C. Legs, feet, and arms stiffly extended, hands turned outward and flexed

D. Legs, feet, and arms flaccid with no motor response

Q7. A primary healthcare provider documents the following Glasgow Coma Scale score in a client's medical record: "GCS 9 = E2 V4 M3 at 0720". What conclusions should a nurse draw from this documentation? SATA *

1 point

1. A severe head injury has been sustained.

2. The client opens the eyes in response to a pain stimulus.

3. The client's speech is incomprehensible.

4. Abnormal flexion is observed in the client.

5. The GCS assessment was performed at 7:20 am.

Required

Q8. A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene?
*

1 point

1.Cyanosis of hands and feet

2.Heart rate of 165/min while crying

3.Jitteriness

4.Respirations of 60/min

Q9. Which infant in the newborn nursery requires an immediate intervention by the nurse? *

1 point

1. At time of birth, covered with grayish-white cheese-like substance.

2. Three hours old, with quivering of the lower lip.

3. Two hours old, having episodes of apnea lasting 25-30 seconds.

4. One hour old, who has acrocyanosis.

Q10. A nurse is performing an assessment on a newborn infant who is 4 hours old. She lightly strokes the infant’s cheek and the baby turns her head in that direction. This reflex is best known as the:

1 point

A. Rooting reflex

B. Sucking reflex

C. Babinski reflex

D. Swallowing reflex

11. You are assessing an 8-month-old infant. Which of the following findings are normal for his developmental age?

Select all that apply.

1 point

A. Posterior fontanel is soft and flat

B. Anterior fontanel is closed

C. Negative Moro reflex

D. Positive Babinski reflex

Required

Q12. The nurse provides care for a newborn who passed meconium stool in utero. The newborn's respiratory rate is 32 breaths/min, heart rate is 114 beats/min, and good muscle tone is present immediately after delivery. Which action is most important for the nurse to take? *

1 point

1. Suction newborn's mouth and nose with a bulb syringe.

2. Assist the newborn's respiratory effort with a resuscitation bag.

3. Dry and wrap the newborn in warm blankets.

4. Request the health care provider suction the newborn's trachea.

Q13. The parents bring their toddler into the emergency department (ED). The nurse observes that the client is having difficulty breathing and appears to be wheezing on inspiration. Which question is most important for the nurse to ask the parents? *

1 point

1. "Is your child's immunization schedule current?"

2. "Do you or the child's siblings have a history of asthma?"

3. "What toy does your child like playing with the most?"

4. "Was your child eating anything immediately before developing breathing problems?"

Q14. The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? *

1 point

A. Primary

B. Secondary

C. Tertiary

D. Quaternary

Q15. The home health nurse is providing care for several pediatric clients. Which client does the nurse identify as being at the greatest risk for injury?
*

1 point

1. An infant who is in a car seat placed on the coffee table.

2. A toddler who is playing alone in the living room.

3. A preschool-age client with a tracheostomy who is eating raisins.

4. A school-age client who stays home alone for half an hour after school.

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