Which nursing measure should assume priority in performing a physical examination on an 8-month-old infant who is sitting contently on his mother’s lap chewing on a toy?
a. Take the toy away so that the mouth can be observed
b. Begin a systematic physical exam, beginning at the head and moving toward the feet
c. Remove all the infant’s clothing so a thorough exam can be performed
d. Auscultate the heart and lungs and then proceed with the rest of the exam
Answer D. The order of the physical exam should be adjusted to accommodate the developmental age of the child and the response of the child to being examined.
Since the child is quiet and distracted with the chew toy, the nurse should be able to get a good listen to the heart and lungs without the child crying or squirming.
a. Take the toy away so that the mouth can be observed
b. Begin a systematic physical exam, beginning at the head and moving toward the feet
c. Remove all the infant’s clothing so a thorough exam can be performed
d. Auscultate the heart and lungs and then proceed with the rest of the exam
Answer D. The order of the physical exam should be adjusted to accommodate the developmental age of the child and the response of the child to being examined.
Since the child is quiet and distracted with the chew toy, the nurse should be able to get a good listen to the heart and lungs without the child crying or squirming.