What is the most accurate method of determining the length of a child less than 12 months of age quizlet?
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2, 3, 4 Show 3. If the blood pressure is over 99th percentile, plus 5 mm Hg 4, 3, 1, 2, 5, 6 Sets with similar termsReview terms and
definitions Focus your studying with a path Get faster at matching terms An oral temperature is appropriate for a 12-year-old child who has not had anything hot or cold to eat or drink recently. An axillary temperature is appropriate for a 3-year-old child. Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods. However, this procedure is more invasive and is contraindicated for infants less than 1 month old, children with recent rectal surgery, children with diarrhea or anorectal lesions, and children receiving chemotherapy. Oral temperatures are considered the standard for temperature measurement but are contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are under 5 years old. This is inconsistent and insensitive in infants and children over 1 month old. Axillary temperatures are inconsistent and insensitive in infants and children over 1 month old. The charge nurse should intervene to assess if a definitive temperature is needed. The temperature may need to be taken by a different route. For infants less than 1 month old, the American Academy of Pediatrics (2001) recommends axillary temperatures. Sets found in the same folderA 4-month-old is sleeping during her well infant checkup. Which assessment should the nurse do first? D. Auscultation Auscultation requires quiet to hear the sounds clearly and should be done first. Inspection of the entire infant and palpation would require moving the infant and could interfere with a quiet environment, which would facilitate accurate auscultation. Percussion is rarely done on infants. It would interfere with a quiet environment, which would facilitate accurate auscultation. The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. What assessment should the nurse make about this infant's development? C. A developmental/neurologic follow-up evaluation is needed. The head lag should be almost gone by 4 months of age. This child requires evaluation by a specialist. A 6-month-old infant should have social interaction beyond smiling and cooing and should no longer have head lag. The assumption that the child is cognitively impaired is unwarranted. The child requires evaluation before appropriate interventions can be determined. The nurse is performing a well-child examination. Which is the most accurate method of determining the length of a child less than 24 months of age? C. Measure the child recumbent in the supine position. The crown-heel length measurement is the most accurate measurement for infants. Children less than 24 months are unable to stand still enough to allow an accurate height measurement. An infant or toddler should be measured in the supine position, not prone. The measurement should not be estimated if an accurate number is needed. The nurse is
performing a basic neurologic assessment of a 6-month-old. How can the nurse accurately assess cranial nerve V? A. Watch how the baby sucks on his pacifier. Cranial nerve V deals with the ability to suck and swallow. The ability to smile is tested with cranial nerve VII Hearing occurs with cranial nerve VIII. Smell is tested using cranial nerve I. The nurse is assessing a preschooler's chest as part of a well-child exam. What normal findings would the nurse expect to document? D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing. The preschooler has a coordinated breathing pattern. For a preschooler, breathing is a coordinated function that uses abdominal breathing as well as a little chest movement. It is incorrect for the anteroposterior diameter to be equal to the transverse diameter. Retraction of the muscles between the ribs on respiratory movement is indicative of respiratory distress. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? D. Have the child "help" with palpation by placing his or her hand over the palpating hand. It allows the nurse to perform the assessment while including the child to have the child "help" with palpation by placing his or her hand over the palpating hand. It would not promote relaxation and would make it more difficult to perform the assessment to palpate another area simultaneously. It might only contribute to the child's laughter to ask the child not to laugh or move if it tickles. It would not promote relaxation and would make it more difficult to perform the assessment to begin with deeper palpation and gradually progress to superficial palpation. When the nurse lifts the skin on the abdomen and releases it quickly to check skin turgor, the tissue remains suspended for
a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly determine from the findings? D. The child is dehydrated. Skin remaining suspended, or "tented," when released is seen when poor skin turgor is related to dehydration. In normal elasticity, the skin would return immediately to its original position. If the child was overly hydrated, the skin would not remain suspended or tented. If the child was properly hydrated, the skin would spring back quickly when released. The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which is the most essential part in this assessment? A. Checking the reactivity of pupils. Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for presence of reactivity, whether the reactivity is equal, and the rate of reactivity. A doll's head maneuver should not be performed if there is a cervical spine injury. Oculovestibular response is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness. This is also not within a pediatric nurse's scope of practice unless there is advanced training and education. The nurse is preparing to assess the lung sounds of a 3-month-old sleeping infant who is being held on her belly by her mother against the mother's upper chest. Which techniques should the nurse use to obtain an accurate assessment? Select all that apply. A. Gently turn the infant on her back prior to beginning the assessment. C, D, F The lungs should be assessed from the apex to the base bilaterally Hyperresonance is normal because of the thin chest wall in infants and young children. Auscultation of the lung sounds through the back can provide accurate data. The infant can remain in the current position for an accurate assessment. She is quiet and her head is elevated against the mother's upper chest. Warm the stethoscope head before placing it directly on the infant's skin, not over the shirt. The infant should be in an elevated position, which she already is in, while listening to the lungs. The nurse is performing a well-child exam. During an otoscopic examination on an infant, in which direction should the nurse gently pull the pinna? C. Down and back Down and back is correct for examining an infant's ear because it slightly straightens the ear canal. Down and forward would not allow sufficient visualization. Up and forward would not allow sufficient visualization. Up and back is the correct position for a child age 3 years or older. The nurse needs to check the blood pressure of a small child with no suspected cardiac problem. Of the cuffs available, one is too large and one
is too small. What nursing action is best? D. Wait to check the blood pressure until a proper cuff can be located. An inaccurate blood pressure is no better than omitting its measurement. Get the appropriate sized blood pressure cuff. Too small of a cuff would give a falsely high blood pressure. Too large of a cuff would give a falsely low blood pressure Auscultation is preferred to palpation. The nurse is ready to begin a physical examination of an 8-month-old infant who is sitting contentedly on her mother's lap, chewing on a toy. Which assessment should the nurse do first? B. Heart and lungs While the child is quiet, auscultation should be performed. Because this is the least intrusive of the options given, it affords the best opportunity to hear the required sounds. Eliciting reflexes might disturb the child, making auscultation afterward difficult. Examining the eyes, ears, and mouth might disturb the child, making auscultation of the heart and lungs afterward difficult. Although examining the head is often the starting point, the nurse should perform the assessments that require quiet and cooperation of the infant first. The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. What evaluation of these findings by the nurse is correct? A. The infant's neurologic status is appropriate. The Moro, tonic neck, and withdrawing reflexes are usually present in infants less than 3 to 4 months old. Therefore, the presence of these reflexes indicates neurologic health. Moro, tonic neck, and withdrawal reflexes are expected in a 2-month-old. These findings are appropriate and normal for a 2-month-old. Decerebrate posturing is indicative of dysfunction at the level of the midbrain. The anterior fontanel appears slightly bulging when a 4-month-old cries. What action by the nurse is indicated? A. Document the findings The finding is normal. Crying causes the fontanel to bulge slightly. There's no need to notify the pediatrician since this is normal. There is no need to check the Moro reflex. The length of time the infant cries has nothing to do with the fontanel bulging. A mother asks the pediatric office nurse why her toddler son needs to be seen by an eye specialist. Which explanation by the nurse to the mother states the importance of detecting and following up strabismus in young children? B. Muscle imbalance can cause loss of vision. Loss of vision may develop if the eyes do not work together. The brain may ignore the visual cues from one eye, resulting in blindness. Color vision is dependent on rods and cones in the retina, not on muscle coordination. Epicanthic folds are present at birth. Symmetric corneal light reflexes are normal and tests alignment of the eyes. It doesn't explain why strabismus testing is important. A cooperative 6-year-old child is being evaluated for a sore throat. Which method should the nurse use to view the tonsils and oropharynx of this child? A. Ask the child to open her mouth wide and say, "Ahh." If the child is cooperative, the child can open her mouth and move the tongue around for the examiner. During crying there is insufficient opportunity to accurately visualize the mouth. Placing the tongue blade in the back of the throat can cause gagging. The child is being evaluated for a sore throat, not a neurologic issue. It would be traumatic and a safety risk to pinch the nostrils closed, forcing the child to open her mouth, and then insert the tongue blade. No reason would warrant such measures, especially with cooperative children. What is the most accurate method of determining the length of a child younger than 12 months of age?What is the most accurate method of determining the length of a child younger than 12 months of age? The crown-heel length measurement is the most accurate measurement in infants. Infants are generally unable to stand for a height measurement.
What is used to measure the length of children under two years old?Recumbent length is used to measure infants and children less than two years of age.
How is length measured in a child?Two practitioners are required in order to obtain accurate measurements of child length; one holding the child's head in the Frankfort Plane; the other maintaining the child in the correct supine position on the measuring board, bringing the movable foot plate up to the heels, and reading the value from the scale.
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