A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?
At the beginning
Before examining the head and neck
At the end
Before auscultating the chest
The Correct Answer is C
A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.
B. Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.
C. Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible. If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.
D. If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.
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Related Questions
Correct Answer is B
Explanation
These foods are rich sources of iron, which is important for treating and preventing iron deficiency anemia. Meats, such as beef, poultry, and fish, provide heme iron, which is more easily absorbed by the body. Eggs and green vegetables, such as spinach and broccoli, contain non-heme iron, which is also beneficial.
While fruits, whole grains, and rice are nutritious foods, they are not as rich in iron as meats and green vegetables. Therefore, they may not provide sufficient iron to address the child's iron deficiency anemia.
Drinking 32 oz of whole cow's milk per day is not recommended for a 2-year-old with iron deficiency anemia. Excessive cow's milk intake can lead to iron deficiency anemia because it can interfere with iron absorption and displace iron-rich foods from the diet. Similarly, consuming 8 oz of juice, three times a day is not recommended for a child with iron deficiency anemia. Juice does not provide significant amounts of iron and can contribute to decreased appetite for iron-rich foods. It is generally recommended to limit juice intake and prioritize whole foods for iron intake.
Correct Answer is D
Explanation
DDH refers to an abnormal development or alignment of the hip joint, which can lead to instability or dislocation of the hip. An asymmetric thigh fold is a common physical finding in DDH, where there is a difference in the skin fold between the affected and unaffected sides of the thigh. This occurs due to the malposition or displacement of the femoral head within the acetabulum.
While other findings may also be present in DDH, such as an inwardly turned foot on the affected side (also known as a positive Ortolani or Barlow test), absent plantar reflexes, or a lengthened thigh on the affected side, the asymmetric thigh fold is a key indicator of hip dysplasia in a newborn.
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