Maternal-Child Nursing: Chapter 29 – Flashcards

4 The convenient position for the examination of the genitalia involves placing the child in a semi-reclining position on a parent's lap, with the feet supported on the nurse's knees. The examination of female genitalia is limited to inspection and palpation of external structures. If the nurse places a child in Fowler position, the nurse may not be able to fully assess the genitalia. In the reclined position, the nurse cannot inspect or palpate the genitalia. At 13 months, the child is unable to stand independently. Inspection can be done in this position, but palpation is not possible. Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

6, 3, 2, 1, 4, 5 The first step in the history-taking process is to identify the person. Then move on to the child's chief complaints. This will determine the reason for the child and parents seeking professional health attention. The child's present illness helps to obtain all the details related to the chief complaints and to plan care accordingly. Past medical history of the child elicits information about previous illnesses or health conditions of which the health care team needs to be aware. The family medical history elicits the role of any genetic diseases and familial tendencies, as well as to assess exposure to communicable diseases. Dietary intake and clinical examination of the nutritional status of a child elicit the adequacy and requirements of the child's nutritional needs.

4 When a child cries, oxygen intake is decreased due to the increased rate and depth of respirations. Alveolar carbon dioxide concentration is higher than body production and it results in hyperventilation. Hyperventilation may be voluntary or involuntary. Dyspnea is distress during breathing or an inadequate breathing pattern due to pathological illness. Dyspnea can also be caused by a respiratory and cardiovascular problem. During times of exercise or after heavy activities, the respiratory pattern that is needed to meet the metabolic demands is termed as hyperpnea. In situations where there is inadequate oxygenation, the pattern of respiration is considered hypoventilation. If it exceeds the limits it may also cause respiratory acidosis.

4 Abnormal heart sounds are called murmurs. These sounds are produced by vibrations within the heart chambers or the back flow of blood in major arteries. If S3 and S4 heart sounds are heard, further evaluation would be needed to detect any abnormalities. S3 heart sounds are normally heard in children but they don't require any further evaluation. S1 and S2 heart sounds are normal heart sounds. Closure of the tricuspid and mitral valves produces S1 sounds, and closure of the pulmonic and aortic valve produces S2 sounds. These sounds provide important auditory data required for assessing the heart. Test-Taking Tip: Survey the test before you start answering the questions. Plan how to complete the exam in the time allowed. Read the directions carefully and answer the questions you know for sure first.

3 The nurse can measure temperature at several body sites, but the axillary route of temperature screening is the recommended site for a toddler. This is a noninvasive and easy way to measure body temperature. An axillary thermometer is placed in the central position under the axilla and the arm is held tight against the chest wall. The oral route is not recommended until children can hold the thermometer under their tongue. The rectal route is recommended for infants when a definitive temperature reading is needed. The tympanic route of temperature screening is recommended in children older than 5 years, and requires good access to the child's ear.

4 It is difficult for parents to recall exactly what their child has eaten . Concurrent food diaries are somewhat more reliable. Systematic tools have been developed and are available. Nutrients for different foods are known; it is the quantity and type of food consumed that are difficult to ascertain. The family does not need nutrition knowledge to describe what the child has eaten.

3 Measurement and interpretation of blood pressure in children requires careful attention and correct procedures. If the child's BP is over 99th percentile, plus 5 mm of Hg, prompt referral is needed. Even if the child is symptomatic, immediate referral and treatment are indicated. If the BP is over 90th percentile, the BP measurement should be repeated twice at the same office visit and an average of systolic blood pressure (SBP) and diastolic blood pressure (DBP) are to be used to confirm the reading. If the BP is over 95th percentile, the BP should be further assessed based on two more measurements. When all the recordings confirm elevated BP, treatment is indicated. If the BP is between 95th to 99th percentile, plus 5 mm Hg, the BP measurement should be repeated twice. If it is confirmed, then referral and treatment is started. Test-Taking Tip: Do not fret over any one question for too long. If you are having trouble, skip the question and go back to it when you have finished answering the other questions.

3 When a child looks down and in, the eye moves down and out. This assesses the superior oblique muscle and the trochlear nerve. Optic nerve assessment is done through checking the perception of light, visual acuity, and peripheral vision. The trigeminal nerve is assessing the sensory perception of the face as well as the scalp, nasal and buccal mucosa. The nurse would also ask the child to bite down, open their jaw, and close their eyes to test for symmetry and strength. The oculomotor nerve is assessed by asking the child to follow the object shown by the nurse or moving a penlight in the six cardinal positions of gaze.

3 Deficiency of vitamins B6 and B12 causes symptoms such as tiredness and fatigue, pale skin, sore tongue, bleeding gums, stomach upset, rapid heartbeat, and mood swings. Muscle weakness, anemia, neurological damage, and alopecia are the primary symptoms due to the deficiency of vitamin E. Excess of vitamin A may cause hardening and scaling of skin, pruritis, jaundice, hair loss, and hard tender lumps in occiput. Defective enamel on teeth, bleeding gums, and softened bones are generalized symptoms of both vitamin C and D deficiency.

3 The judicious use of telephone triage has decreased the number of unnecessary visits, allowing time for improved care. Health care costs have decreased because of fewer visits to emergency departments. Based on the response to screening questions, the triage nurse determines whether the child needs to be referred to emergency medical services. The nurse can then initiate the call if needed. Home care is recommended only when indicated on the basis of the screening questions.

2 Amblyopia may develop if the eyes do not work together. Color vision depends on rods and cones in the retina, not muscle coordination. The brain may ignore the visual cues from one eye, resulting in blindness. Epicanthal folds are present at birth. Ptosis, or drooping eyelids, is not related to strabismus (or cross-eyes). Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

3 The nurse should observe the posture, position, hygiene, and type of body movements when assessing the child. A slumped, careless, and apathetic pose are characteristics of a child with low self-esteem or feelings of rejection. The child with pain may be guarded and look anxious due to the inability to handle the pain. A child with hearing or vision loss may characteristically tilt the head in an awkward position to hear or see better. A child with feelings of self-worth usually has a straight, well balanced posture, and has feelings of security.

2 Rectal temperature recording provides the most accurate core body temperature measure for infants from birth to 2 years of age. Thus, the nurse should use the rectal temperature measurement for the infant. The infant would not be able to hold the thermometer under the tongue. and thus oral measurement should not be used for a 3-month-old infant. Axillary temperature recording is the most convenient temperature recording method in infants. However, it does not give an accurate temperature reading. Tympanic method of temperature recording is not suitable for children younger than 2 years of age because it can damage the tympanic membrane of the ear.

2 Bronchial breath sounds can only be heard over the trachea near the suprasternal notch. These breath sounds have a short inspiratory phase and a long expiratory phase. The child is blowing out continuously so this can be clearly auscultated. The inspiratory and expiratory phases may not be equal because the child takes short inspirations and exhales deeply to blow out the light. When auscultating vesicular lung sounds over the lung fields, the inspiratory phase is long and the expiratory phase is short. The inspiratory and expiratory phases cannot both be too long.

2 If the child is older and cooperative, the nurse can examine the mouth and throat with the help of a tongue blade. However, in younger children it is difficult. The nurse should demonstrate the procedure on a parent or puppet and explain how important it is to let the nurse look in their mouth. The nurse should instruct the child to tilt the head back slightly, take a deep breath through the mouth, and then hold the breath. This action lowers the tongue to the floor of the mouth and allows the nurse to examine the mouth and throat. Instructing the child to follow the same actions as the nurse would not help the nurse to visualize the mouth. If the nurse tells the child to say "ahh" and keep the mouth open, the child may not cooperate or the child may close the mouth due to pain. If the child turns the head sideways, the nurse may not be able to assess the mouth and throat. If the nurse tells the child to tilt the head backward, hold the nose tip upward, and say "ahh", the nurse may not be able to view the mouth. This position helps the nurse to assess the nose.

1, 2, 5 Sexual history is a component of the health history. Review of systems is a component of the health history. Review of family medical history is a component of the health history. Physical assessment is a component of the physical examination. Growth measurements are a component of the physical examination.

1 The findings obtained from the nutritional assessment of the child indicate that the child is malnourished. The signs and symptoms of malnutrition are based on deficiencies. Fatigue, low energy levels, dry and scaly skin, and the bloating in the stomach are generalized symptoms that indicate that the child is malnourished. If the child is overweight or obese, the child will have irregular eating patterns, abnormal body growth, and will have a higher body weight with respect to height. There is no evidence of cancer in the question. If the child is well nourished, the child would not show signs such as fatigue and scaly skin.

1 Dizziness (vertigo), feeling faint (syncope), and lightheadedness are manifestations of postural hypotension or orthostatic hypotension. A sudden drop of 20 mm Hg in SBP and 10 mm Hg in DBP causes the manifestations of orthostatic hypotension. A sudden drop of 10 mm Hg in SBP and 20 mm Hg in DBP cannot occur because SBP always drops more than DBP. A sudden elevation of 20 mm Hg in SBP and 10 mm Hg in DBP, and a sudden elevation of 10 mm Hg in SBP and 20 mm Hg in DBP, do not present with these symptoms.

1 If the child is cooperative, the child can open his or her mouth and move the tongue around for the examiner. A tongue blade is not necessary to visualize the tonsils and oropharynx if the child cooperates. During crying, there is insufficient opportunity to completely visualize the tonsils and oropharynx. It is inappropriate to pinch the nostrils closed, especially with cooperative children. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

4 Tenting is the term for poor skin turgor. In normal elasticity the skin returns immediately to its original position. If the child is properly hydrated, skin turgor is elastic. The assessment was done correctly. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

1 Correct position for an infant's ear examination is to pull the pinna down and back. Pulling the pinna down and forward is the correct position for a child age 3 years and over. Pulling the pinna up and forward or up and back will not allow sufficient visualization of the ear.

4 Vesicular breath sounds can be heard over the entire surface of the lungs, with the exception of the upper intrascapular area and area beneath the manubrium. These sounds are characterized based on the variation between inspiration and expiration. Inspiration is louder, longer, and higher pitched than expiration. Shorter inspiratory sounds and longer expiratory sounds are characteristic of bronchial sounds and heard only over the trachea. If the inspiratory phase is louder and longer than expiration, this may signal a pulmonary obstruction or respiratory problems not normally found in children.

4 If the pulse is graded as +1, the pulse is difficult to palpate, thready, weak, and easily obliterated with pressure. If the pulse is strong, bounded, and not obliterated with pressure, the grade is +4. If the pulse is difficult to palpate and may be obliterated with pressure, then it is graded with a +2. If the pulse is easy to palpate and not easily obliterated with pressure, then the grade is +1.

4 Having the child help with palpation allows the nurse to perform the assessment while including the child in the care. Palpating another area simultaneously does not promote relaxation and makes it more difficult to perform the abdominal assessment. Asking the child not to laugh may only contribute to the child's laughter or may prove frustrating to both the child and the nurse. Deeper palpation enhances the "tickling" sensation instead of lessening it.

1 Assessment of the cranial nerves is an important area of the neurological assessment. The facial nerve is referred to as the VII cranial nerve. The nurse assesses the function of the facial muscles and the anterior two thirds of the tongue (sensory). The vagus is the X cranial nerve and it controls the muscles of the larynx, pharynx, and some organs of the gastrointestinal system. The optic nerve is the cranial nerve II and controls the vision and the rods and cones of the retina. The trochlear nerve is the cranial nerve IV and controls the superior oblique muscle.

4 To obtain an accurate blood pressure reading, it is preferable to use the proper-size cuff. Locating one before taking the blood pressure is the best nursing action. The smaller cuff gives a falsely increased blood pressure and is not the method of choice. The larger cuff (which may give a falsely lowered blood pressure) is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation.

1 The interpreter should be given guidance about what information is necessary to obtain during the interview. One question should be asked at a time, leaving sufficient time for the family to answer. The interpreter should not have to guess what to ask and what information to obtain during the interview. The interpreter should gain as much information from the family as they are willing to share based on the questions posed. Limits should not be placed on the interview.

1 Testing reflexes is an important part of the neurological examination. The child's arm is held by placing the partially flexed elbow in the examiner's hand with the examiner's thumb over antecubital space. The normal response is partial flexion of the forearm. The triceps reflex is elicited by placing the child in a supine position with the forearm resting over the chest and stimulating the triceps tendon. Normal response is partial extension of the forearm. During the assessment of the patellar reflex, the child sits on the edge of the examining table with the lower legs flexed at the knee and dangling freely. The patellar tendon is tapped and the response is partial extension of the lower leg. When the nurse is assessing the Achilles reflex, the child is placed in the sitting position and the foot is supported lightly in the examiner's hand. The Achilles tendon is struck and the normal response is plantar flexion of the foot.

3 The grading of pulses is done on the basis of the strength of the pulsations. If the pulse is difficult to palpate and may be obliterated by pressure, then the grade of the pulse is +2. If the pulse is not palpable, then the grade of the pulse is 0. If the pulse is strong and pounding, then the grade of the pulse is +4. If the pulse is easy to palpate and is not easily obliterated by pressure, then the grade of the pulse is +3.

2, 6, 1, 5, 3, 4 Foreign bodies in the ear are common, and removal of these foreign bodies prevents infection and ear damage. Six steps are involved in the removal of a foreign body. At first, the nurse determines what type of foreign object there is in the ear canal, using a flashlight or sometimes using an otoscope. After identifying the object as soft or hard, vegetative or an insect, the next step is to keep the equipment tray ready for the removal of the foreign body. The nurse should reassure the child that it will not be painful. This will help reduce stress and increase cooperation. Proper positioning of the child is an important step in the removal because movement of the child may push the foreign body further into the ear canal and hurt the child. The nurse then removes the foreign body completely without leaving any parts or breaking the foreign object. In the last step, the nurse shows the foreign body to the child and parents, and reassures them that there is no damage. The nurse will also teach the parents to administer any medications prescribed by the health care provider.