MEDizzy - Which nursing measure should assume priority when performing

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Health Promotion and Maintenance II

Which nursing measure should assume priority when performing a physical examination on an eight-month-old infant who is sitting contentedly on his mother’s lap chewing on a toy?

ExplanationThe order of the physical exam should be adjusted to accommodate the developmental age of the infant and the infant’s response to being examined. Assess the heart and lungs while the child is quiet and distracted with the toy. Taking the toy away might cause the infant to cry, and, while the nurse might get a good look in the mouth, the respiratory, cardiac, and abdominal assessments are compromised. Children are usually late-preschool or school-age before the nurse can do a complete head-to-toe exam without making adjustments in the order of the exam. Ear and mouth assessment is viewed as invasive and might prompt crying in infants, toddlers, and many preschoolers. Delay ear and mouth assessment until after respiratory, cardiac, and abdominal sections are completed. By delaying this until the end, good respiratory, cardiac, and abdominal assessments can be done. Remove the infant’s clothing one item at a time. Removing all the infant’s clothing at once might prompt crying. The stethoscope can be slipped under clothing without prompting crying