CHAPTER 18: ASSESSING CHILDREN: INFANCY THROUGH ADOLESCENCE

MULTIPLE CHOICE 1. A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? a. Gravida 3, para 4 b. Gravida 4, para 3 c. This information cannot be documented using the terms gravida and para. d. The patient seems to be confused about how many times she has been pregnant. ANS: A Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins. DIF: Cognitive Level: Applying (Application) REF: p. 807 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: a. Epigastric hernia. b. Pyloric obstruction. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds. ANS: D A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia (see Chapter 21). DIF: Cognitive Level: Analyzing (Analysis) REF: p. 572 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to: a. Need to be held on his mothers lap. b. Be able to sit on the examination table. c. Be able to stand on the floor for the examination. d. Be able to remain alone in the examination room.