A nurse is preparing to perform an abdominal assessment on a child.
Identify the sequence the nurse should follow.
Inspection.
Auscultation.
Superficial palpation.
Deep palpation.
The Correct Answer is A,B,C,D
A. Inspection: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B. Auscultation: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C. Superficial palpation: This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D. Deep palpation: This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answer is Choices A, D, and E.
Choice A rationale
The Measles, Mumps, and Rubella (MMR) vaccine is recommended for children at 12-15 months of age. This vaccine protects against three serious diseases: measles, mumps, and rubella. Measles can cause severe respiratory illness and encephalitis, mumps can lead to meningitis and hearing loss, and rubella can cause congenital rubella syndrome in unborn babies if a pregnant woman is infected.
Choice B rationale
The Rotavirus (RV) vaccine is typically given to infants at 2, 4, and sometimes 6 months of age. It is not recommended for children older than 8 months.
Choice C rationale
The Human Papillomavirus (HPV) vaccine is recommended for preteens starting at age
11 or 12. It is not given to 1-year-old children.
Choice D rationale
The Varicella (VAR) vaccine is recommended for children at 12-15 months of age to protect against chickenpox, which can cause severe skin infections, pneumonia, and encephalitis.
Choice E rationale
The Diphtheria, Tetanus, and Acellular Pertussis (DTaP) vaccine is part of the routine immunization schedule for children, with doses given at 2, 4, 6, and 15-18 months of age. This vaccine protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which can cause muscle stiffness and lockjaw; and pertussis (whooping cough), which can cause severe coughing spells and pneumonia.
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.
Choice B rationale:
Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.
Choice C rationale:
Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.
Choice D rationale:
Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.
Choice E rationale:
Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.
Choice F rationale:
Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.
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