31. What is the earliest age at which a satisfactory radial pulse can be taken in children?

a.1 year

b.2 years

c.3 years

d.6 years

32. Pulses can be graded according to certain criteria. Which is a description of a normal pulse?

a.0

b.+1

c.+2

d.+3

33. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

a.Face

b.Buttocks

c.Oral mucosa

d.Palms and soles

34. The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. This should be interpreted as:

a.normal.

b.erythema.

c.jaundice.

d.ecchymosis.

35. When palpating the child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?

a.Some form of cancer

b.Local scalp infection common in children

c.Infection or inflammation distal to the site

d.Infection or inflammation close to the site

36. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse’s most appropriate action?

a.Teach parents appropriate exercises.

b.Recheck head control at next visit.

c.Refer child for further evaluation.

d.Refer child for further evaluation if anterior fontanel is still open.

37. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child’s head (opisthotonos) with pain on flexion. Which is the most appropriate action?

a.Refer for immediate medical evaluation.

b.Continue assessment to determine cause of neck pain.

c.Ask parent when neck was injured.

d.Record “head lag” on assessment record, and continue assessment of child.

38. At what age should the nurse expect the anterior fontanel to close?

a.2 months

b.2 to 4 months

c.6 to 8 months

d.12 to 18 months

39. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is a(n):

a.normal finding.

b.abnormal finding, so child needs referral to ophthalmologist.

c.sign of possible visual defect, so child needs vision screening.

d.sign of small hemorrhages, which will usually resolve spontaneously.

40. Parents of a newborn are concerned because the infant’s eyes often “look crossed” when the infant is looking at an object. The nurse’s response is that this is normal based on the knowledge that binocularity is normally present by what age?

a.1 month

b.3 to 4 months

c.6 to 8 months

d.12 months