Chapter 4: Communication and Physical Assessment of the Child and Family - Nurselytic

Correct Answer: B

Rationale: Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.

Correct Answer: B

Rationale: Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.

Correct Answer: B

Rationale: If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.

Correct Answer: C

Rationale: Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva.

Correct Answer: C

Rationale: Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.