Pediatric Assessment Exam 1
Card Set Information
Pediatric Assessment Exam 1
lccc ADN Nursing Pediatric
For Gosselins Exam 1
What position should the child be to chart height and weight? Where do you chart height and weight?
Infant should be naked and supine on scale, children older than 2 year can stand on scale
Height, weight and head circumfrence measured on growth chart
By 6 mo the baby should be double the birth weight and by 1 yr they should be triple the birth weight
In what order should you assess pediatric vital signs?
Least intrusive to most intrusive
: resps, apical, bp, temp (if oral, axill, rectal)
What is the normal HR for a newborn, infant, preschooler, and school age child?
: 125-190 bpm
: 120-160 bpm
What is the normal Resp Rate for a newborn, infant, preschooler, and school age child?
What is the normal BP for a new born, infant, preschooler and school age child?
What size BP cuff should you use for a newborn, infant, preschool, and school age child?
: 1.5in cuff
: same/as per size
: 3in cuff
: 4.5 in cuff
What are some things to remember about taking a pediatric BP (in terms of technique)
Be sure to use the correct size
May use arms and legs (if you think its inaccurate, recheck!!)
Dynamaps are most frequently used
Always explain procedures and expected sensations (tight squeeze)
What are the techniques of a physical examination?
At what age can you expect the anterior and posterior fontanels to close?
: 6-8 weeks
: 12-18 months
What should you assess for the eyes?
Assess placement and alignment
Eyes should track (binocularity) by 3-4 months of age
How do you assess the pediatric ear?
Look for Pinna placement, the top attachment should match an imaginary line to the eyes
<3yrs old= pull pinna DOWN and back
>3yrs old= pull pinna UP and back
How do you assess the child's auditory reaction?
Infants reflex to noise (whisper or name)
After preschool age, rhinne and weber may be used
What specific infection would you be assessing for in the infants mouth?
Mucus membranes should be pink, moist, and shiny
Uvula should be midline
No obvious lesions or swelling
: look for white patches in the mouth that do not scrape away
What are normal assessment findings for the neck?
Trachea should be midline and neck should be symmetrical
Lymph nodes may or may not be palpable (neck, in front of ears, groin). If palpable, should be small, nontender and movable
Check neck ROM- if there is pain or leg flexion with forward flexion of the neck, meningitis is suspect
What are some normal and abnormal assessments for the chest?
Chest should be round and becomes more oval at preschool age
Head circumference larger than chest until age 3 (usually equal by age 2)
At birth, may have edema in breasts and milk discharge (witch's milk)
During a respiratory assessment, what are some normal and abnormal findings?
Asses resp rate and regularity
Assess for adventitious breath sounds, as well as grunting from the the baby
Describe the quality of the child's cry and look for circumoral cyanosis
Pulse ox needs to be higher than 94%
Name the proper placement of the stethoscope to hear pediatric heart sounds
Right 2nd ICS
: Aortic Valve
Left 2nd ICS
: Pulmonary Valve
Left 4-5th ICS
: Mitral Valve
Right 4-5th ICS
: Tricuspid Valve
What is sinus arrhythmia?
In school age to adolescent children, the HR increases during inspiration and slows down during expiration.
This is a normal finding
What would be an abnormal heart sound?
Hearing S4 (
) is an abnormal finding
: it is abnormal filling of ventricles
S3 (TENN-e-see) is a normal finding with rapid ventricular filling
Heart murmurs may be functional (in a certain physical position) or pathologic
What are some normal and abnormal findings in an abdominal assessment?
Infants may have a pot belly
BS should be +4Q
While palpating abdomen, look for guarding by the child
The umbilicus should have a fascial ring no more than 2cm around
Peristalsis may be visible in newborns, but may signify a bowel obstruction in children
Assess for jaundice and ask parents about bowel movements and vomitting
Describe the normal assessment findings for female genitalia
Genitalia should be symmetrical and absent of bruising or swelling (indicative of trauma and abuse)
Labia minora is larger in infants
Observe for the tanner stages of pubic hair and breast development
Secondary sex characteristics should appear prior to menstration
Teach adolescents about STDs and pregnancy prevention
Describe the normal and abnormal findings for male genitalia
Assess for Tanner stages
Assess for placement of urinary meatus (if on top of penis, called epispadias. If on the bottom of the penis, called hypospadias)
Is the male circumcised?
The foreskin is difficult to retract in children <3yrs
After 4 years of age, if the foreskin can not be retracted it is called phimosis
Left testes should be slightly lower than right
May place finger over inguinal canal during palpation of the testes
Hydrocele is a fluid filled sac in scrotum
Variocele is an enlarged vein in the epididymus
How do you assess for inguinal hernias?
Observe the groin area for bulging, especially when crying
For school age to adolescent children, you can put finger on inguinal canal and have them cough
Palpate the femoral nodes for swelling and infection
How would you assess the pediatric anus?
Look for symmetry in the gluteal folds (if not symmetric, may signify displaced hips)
Observe for polyps or prolapse
Look for the anal reflex with tapped with thermom
What may you find during an assessment of the extremities?
Look for symmetry in size, tone and strength
Asses ROM, poldactyly and webbing of digits
Infants and toddlers have bow legs (Genu varum)
Genu valgum is knock knees
Look for the color of nails and look for disformities that may indicate anemia, hypoxia or endocarditis
Capillary refill should be <2sec
Look for acrocynosis of extremities (common at birth until 5min APGAR)
Describe abnormal findings of the back and spine
Observe for normal curvature and symmetry
: pinpoint opening at base of spine
Spina Bifida Occulta
: tuft of hair or hemangioma (defect of the canal, but not complete spina bifida)
: dermal cyst that may cause dimpling
Scoliosis screening should be performed beginning at age 12
How would you assess normal neurologic findings?
Assess deep tendon reflexes for motor and sensory function
Assess balance and coordination
Mental Status (A+O)
Assess cranial nerves (make fun faces)
Babinski reflex may be active until age 2
What assessment tool is sued for developmental assessment? What is this tool looking at?
Denver Developmental Screening Test
It looks at personal-social, fine motor, gross motor, and language
What is the best way to assess newborn and infant I/O?
Measure all input
Measure output according to number of wet diapers or by weight of diapers
1gm=1cc of fluid
What is the best indicator of hydration?