PEDIATRIC NURSING EXAM 1 REVIEW

PEDIATRIC NURSING EXAM #1 STUDY
GUIDE
INFANT/TODDLER [5 Questions]

(INFANT) Physical exam/assessment:
▪ Measuring an infant
o Length supine (done up until 36 months)
o Fully extend body holding head midline
o Measure top of head to heels of feet (dorsi flexed position)
o Standing measurement is height
▪ Obtaining a weight
o Use infant scale
o Balance scale before each weight
o Weigh nude
▪ Obtaining head circumference
▪ Smile and let baby touch equipment
▪ Have parent hold baby during exam
▪ Start from least intrusive to most intrusive (listen to heart & lungs
before anything else such as BP)
▪ Tearless cry normal until 3 months old
▪ Posterior fontanel closes by 2 months
o The younger the baby the WIDER the fontanel
o If not closing worried about microcephaly…brain needs room to grow
▪ Anterior fontanel closes by 12 months
▪ Teeth eruption 4 to 8 teeth by 1 year
▪ Check ear alignment
o Worried about head shape, genetics
o Ears lower than normal could indicate possible Down Syndrome
▪ Lower edge of liver sometimes felt
▪ Legs appear bowed until lower back & leg muscles are well developed
o Haven’t developed the tone to straighten legs yet
▪ Looking for uneven gluteal folds or Ortolani’s click/clunk
▪ Feet may turn in or out OK if feet return to normal position
o If you can’t…club foot & needs casting
▪ Blood-tinged vaginal mucous OK if newbornfrom utero or the mother
▪ Foreskin not retractable until 1-2 years old
▪ Nose breathers until 5 months old
o Don’t know how to open mouth to breathe
▪ Plot height, weight, & head circumference on growth chart EVERY visit
▪ BMI for those > 2 years old
▪ Positive red reflex bilaterally
▪ Denver IIdevelopmental screening tool

, ▪ FLACC Pain Scale
o Face
• 0: No expression
• 1: Occasional grimace
• 2: Frequent to constant quivering chin
o Legs
• 0: Normal position or relaxed
• 1: Uneasy restless, tense
• 2: Kicking or legs drawn up
o Activity
• 0: Lying quiet
• 1: Squirming, shifting back & forth, tense
• 2: Arched, rigid, or jerking
o Cry
• 0: No cry
• 1: Moans or whimpers
• 2: Crying steadily
o Consolability
• 0: Content, relaxed
• 1: Reassurance, hugging
• 2: Difficult to console

(INFANT) Anticipatory guidance:
▪ Sleep
o Birth-3 months10-16 hours
o 3-6 months14 hours
o 6-12 months12-14 hours
o As they get older, they need sleep less & less
o Put baby in dark, quiet room
o Provide blanket
o Have a constant routine
o Put baby in crib while still awakelearn to fall asleep & calm themselves
o Back to sleepprevent SIDS, concerned about this before they can turn
over
▪ Oral health
o Wipe gums 1-2 times/dayespecially after last feeding, warm water &
wash cloth
o No bottle in beddental caries
o When teething offer safe cool teething toys for comfort
▪ Mental health
o Good growth

, o Child & parent interactioneye contact, secure holding/cuddling,
comforting
o Also concerned about health of mother (postpartum depression?)
o Infant’s ability to self comfort
▪ Play
o Play with infant daily
o Vocalize frequently, 12-15 inches from face)
o Read to infant6 months
o Floor time aka “tummy time”
• Back of head gets flat from being on back, loss of muscle tone
in neck
o Grasp large toys, shakes rattle
▪ Disease prevention
o Vaccines
▪ Injury prevention
o Infant car seat (rear facing for neck protection)
o Crib safety (rails up, avoid toys in crib)
o Sleep on back
o Toy safety
o Violence in the home (never shake the baby)
o Install gates/guards on stairs & windows
o Use safety plugs for outlets
o Avoid string toys, necklaces, cords near the infant
o Poison control

(INFANT) Nutrition:
▪ Feedings should be “on demand”depends on size of the baby & the baby itself
▪ Newborn-3 months
o 1-6 oz. every 2-4 hours
o No solid foods
▪ 4-6 months
o 6-8 oz. every 4-6 hours
o Iron fortified cereals, fruits, & vegetables
▪ 7-11 months
o 6-8 oz. every 6-8 hours
o Maximum of 32 oz./day
o Offer finger foodmore about oral motor skills, good head control,
picking up food to mouth, & chewing
▪ Milk based formula
▪ Soy based formula
▪ Preparations:
o Ready to feed