Review Practice Exercise 2

Childhood And Family Assessment > Child Health

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Practice Exercise 2

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Total Questions : 4

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Question 1:

A sleeping 5-month-old girl is being held by the mother when the nurse comes in to do a physical examination. What assessment should be done initially?

A. Listening to the bowel sounds B. Counting the heart rate C. Checking the temperature D. Looking in the ears

Answer and Explanation

Choice A:

Listening to bowel sounds can be done at any time, as bowel activity is not greatly affected by the infant’s state of alertness. It is not as time-sensitive as heart rate.

Choice B:

For infants, heart rate assessment should be performed first when they are calm or asleep because crying or activity can significantly elevate the rate. Accurate baseline readings are important for clinical evaluation, and the apical pulse should be counted for a full minute.Rationale for incorrect answers:

Choice C:

Checking temperature requires handling the infant more actively, which could wake her and cause distress before important calm-state measurements are taken.

Choice D:

Looking in the ears often requires restraint and is uncomfortable for the infant, likely waking and upsetting her, making it harder to obtain accurate vital signs afterward.

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Question 2:

Which assessment finding is considered normal in children?

A. Irregular respiratory rate and rhythm B. Split S2 and sinus arrhythmia C. Decreased heart rate with crying D. Genu varum past the age of 5 years

Answer and Explanation

Choice A:

An irregular respiratory rate and rhythm outside the newborn period may indicate respiratory or neurologic issues; while periodic breathing can be normal in infants, it is not considered typical in older children.

Choice B:

Sinus arrhythmia results from normal vagal tone variation with respiration. The heart rate increases with inspiration and decreases with expiration. A split S2 occurs because the aortic and pulmonic valves close at slightly different times during inspiration, which is normal in healthy children.Rationale for incorrect answers:

Choice C:

Crying generally increases, not decreases, the heart rate due to sympathetic stimulation; bradycardia with crying is abnormal and requires further evaluation.

Choice D:

Genu varum (bowlegs) is normal in toddlers but usually resolves by age 2–3; persistence beyond age 5 suggests underlying pathology such as rickets or Blount disease.

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Question 3:

A nurse is attempting to get a 5-year-old child’s cooperation when auscultating heart sounds. Which of the following comments is most likely to elicit the child’s cooperation?

A. “It’s time for me to listen to your heart go boom boom.” B. “Did you know that your heart beats in your chest?” C. “Would you like to listen to the sounds your heart makes?” D. “Let me show you a picture of a heart and where I want to listen.”

Answer and Explanation

Choice A:

While using playful language like “boom boom” may be friendly, it does not engage the child’s participation as effectively as offering them the chance to listen.

Choice B:

Providing information (“Did you know that your heart beats in your chest?”) may pique curiosity but is less likely to actively involve the child in the procedure.

Choice C:

Involving the child in the examination turns the assessment into an interactive activity rather than a passive procedure. At age 5, children are naturally curious and enjoy hands-on participation, which can reduce anxiety and increase cooperation.Rationale for incorrect answers:

Choice D:

Showing a picture is educational but does not directly invite the child to engage in the examination.

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Question 4:

The nurse enters the examination room of a mother and her 8-month-old. The baby is asleep in the mother’s arms. Which of the following actions would be best for the nurse to perform at this time?

A. Ask the baby’s mother for an updated history since the last well-child check. B. Auscultate the baby’s heart, lung, and bowel sounds. C. Begin a full body assessment, starting with the baby’s head and neck. D. Wake the baby by playing with the baby’s toes and feet.

Answer and Explanation

Choice A:

While obtaining an updated history is important, it can be done after completing quiet-state assessments. The priority is to take advantage of the infant’s current calm state.

Choice B:

Heart, lung, and bowel sounds are best assessed when the infant is quiet or asleep to minimize interference from crying or movement. Starting with the least invasive and least disturbing assessments preserves cooperation and accuracy.Rationale for incorrect answers:

Choice C:

Beginning a full head-to-toe exam would require more handling and could wake the baby, making it difficult to get accurate auscultation findings afterward.

Choice D:

Waking the baby unnecessarily disrupts the opportunity for a calm, accurate examination and may make the rest of the assessment more challenging.

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Practice Exercise 2

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