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1. Basavanthappa BT ISBN 9789351529002 DOI 10.5005/jp/books/12612_3 Edition 1/e Publishing Year 2015 Pages 37 Author Affiliations 1. Govt College of Nursing, Fort, Bengaluru, Karnataka, Government College of Nursing, Bengaluru, Karnataka, India, PhD Guide for Research Work, Govt. College of Nursing, Fort, Bengaluru, Karnataka, India, Govt. College of Nursing, Fort, Bangalore, India, Govt. College of Nursing, Fort, Bangalore, Government College of Nursing, Bengaluru, Karnataka, PhD Guide for Research Work, Govt College of Nursing, Bangalore, Government College of Nursing, Fort, Bengaluru, Karnataka, India, Government College of Nursing, Bengaluru, Karnataka, Government College of Nursing, Bengaluru, Karnataka, India, Raja Rajeswari College of Nursing, Bengaluru, Karnataka, India; Faculty of Nursing, RGUHS, Karnataka, India and Academic Council, RGUHS, Karnataka, India; UG, PG and Doctoral Courses on Nursing, Various Universities; Nursing Research Society of India, New Delhi, India, Trained Nurses Association of India, New Delhi, India; RGUHS, Nursing Teachers Association, Karnataka, India, Raja Rajeswari College of Nursing, Bengaluru, Karnataka, India; Faculty of Nursing; Academic Council, RGUHS, Karnataka, India; UG, PG and Doctoral Courses on Nursing, Various Universities; Nursing Research Society of India; Trained Nurses Association of India, New Delhi, India; RGUHS, Nursing Teachers Association, Karnataka, India Chapter keywords Pediatric client, health interview, caregivers, demographics, pediatric nursing assessment form, toddlers and preschoolers, body measurements Learn how to assess the six cardinal fields of gaze as a nurse. In nursing school, you will have to complete a nursing head-to-toe assessment and during this assessment you will have to assess the six cardinal fields of gaze. What is the purpose of assessing the six cardinal fields of gaze? It helps to determine how well the six extraocular eye muscles are working along with cranial nerves III, IV, VI.
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More nursing skills
Terms in this set (16)Which technique would the nurse use to assess patency of the anus in a 1-day-old neonate? 4 The
nurse would check for the passage of meconium in a neonate within 24 to 48 hours to assess the patency of the anus. The trunk incurvation reflex helps determine spinal cord and nerve functioning. Symmetry of gluteal folds helps determine hip abnormalities, not patency of the anus. Inspection for tufts of hair determines abnormal formation; it does not assess patency of the anus. Which reflex would be assessed when the nurse inserts
a gloved little finger into the newborn's mouth? 3 When the nurse places a gloved finger into the newborn's mouth, it triggers the newborn's sucking reflex. To assess the rooting reflex, the nurse strokes the infant's cheek. To test the startle reflex, the nurse would jar the side of the crib or make a loud noise, not insert a little finger into the newborn's mouth. To test the
Babinski reflex, the nurse would gently stroke the outer side of the newborn's foot. Which pulse would the nurse palpate to determine the blood supply to the child's lower extremities? 2 The nurse palpates the dorsalis pedis pulse to determine the blood supply to the child's lower extremities. The apical
pulse is located in the chest. The radial pulse is located in the wrists. The carotid pulse is located in the neck, not the lower extremities. Which reflex would be assessed when the nurse places a thumb in the infant's palm? 1 The reflex the nurse is assessing is the grasp reflex. When the nurse places a thumb or finger in
the infant's palm, the infant shows a reflex response by holding the nurse's finger tightly. Therefore by placing a thumb in the infant's palm, the nurse would determine the presence of the grasp reflex in the infant. The nurse would use a reflex hammer to assess the biceps reflex in the infant. To assess the rooting reflex, the nurse would gently touch the infant's cheek with a finger and would look for the sucking reflex. To assess the Babinski reflex, the nurse would apply gentle pressure on
the outer portion of the sole of the infant's foot. Which intervention would the nurse incorporate to assess a child's cardinal positions of gaze? 2 A moving penlight is directed in front of the eye to assess the cardinal positions of gaze. The nurse assesses a child's eye by covering it with an index card or thumb while performing the cover test. An ophthalmoscope is not used to assess the cardinal positions of gaze. It is used to elicit the red reflex and inspect the fundus. The cardinal positions of gaze do not include assessment of the blink reflex with the help of a penlight. Which intervention helps the nurse listen to the lung sounds in a young child? 4 A pinwheel can help the nurse listen to the child's
lung sounds when that child blows on it during the examination. The child may not fear the tongue blade after examining it; however, it does not help the nurse listen to the child's lung sounds. The nurse evaluates the child's activity tolerance by having the child exercise. The child understands the use of a stethoscope after listening to a parent's heartbeat, but this intervention doesn't allow the nurse to listen to lung sounds. Which
vital signs would the nurse generally take while assessing a healthy neonate? Select all that apply. 2 The regular assessment of vital signs in a healthy neonate includes the measurement of the pulse, respiration, and temperature. The nurse does not generally assess pain, which is often absent in the healthy neonate.
Blood pressure is not usually measured in a neonate. For which reason would the nurse place an index card over a child's left eye during an eye examination? 3 While performing the cover test, the nurse would cover the child's eye with
an index card. The nurse would use an ophthalmoscope to test the red reflex in the child. The nurse would use an ophthalmoscope to inspect the fundus. To test the blink reflex, the nurse would focus a penlight on the child's eyes, not cover one eye with an index card. Which assessment would the nurse include during the examination of a child's head and face? 3 The nurse inspects the size and shape of the head while examining a child's head and face. Fontanels, suture lines, and molding are not assessed in the child. The nurse assesses the fontanels of an infant for bulging while crying and at rest. The fontanels and suture lines of an infant are palpated to identify the presence of swelling. A
newborn is examined for the molding of the head after birth. Which action would the nurse take after examining a child's ears? 1 The posterior chest is inspected after the child's ears are assessed. The posterior chest is inspected for configuration, skin characteristics, and symmetry of shoulders and muscles. The anterior thorax is assessed after the posterior chest. Heart sounds are auscultated after inspection and palpation of the anterior chest. The pupillary light reflex is tested during the eye examination. Which assessment would the nurse evaluate as a young child plays with toys in the examination room? 2 The nurse assesses the gross and fine motor skills while the child plays with toys. The nurse observes the child while walking to assess alignment of the legs. The size and shape of the child's head are inspected during an examination of the head and neck. The nurse notes the parent and child interaction during the course of the
examination. Which intervention would the nurse use to gain a preschooler's cooperation during an otoscopic examination? 4 To gain the preschooler's cooperation, the nurse would allow the child to handle the otoscope and test the parent's ear. This intervention decreases the preschooler's curiosity and enables the child to get involved in the test. Preschoolers demonstrate exploring behavior and may refrain from sitting still during an examination. If the nurse restrains the preschooler, the child may become afraid of the nurse. Doing this would not facilitate a trusting relationship with the
nurse, and the preschooler may not cooperate. The preschooler also may feel rejected if the nurse talks in a firm voice. Behaving in this way does not help the nurse gain the child's cooperation. The nurse would not ask the parents to firmly hold the preschooler as this will not help with cooperation. Which reflex would the nurse assess for when using an ophthalmoscope? 1 The nurse assesses the red reflex by using an ophthalmoscope during an eye examination. A penlight is used to assess the blink reflex, the pupillary reflex, and the corneal light reflex. At which time would the nurse perform the initial Apgar test in a newborn? 1 Which methods would trigger the Moro reflex in an infant? Select all that apply. 1 The Moro reflex is triggered by jarring the infant's crib, by any loud noise, or by dropping the infant's head suddenly for a short distance. Tapping lightly on the biceps and examining the eyes under an ophthalmoscope do not cause sudden loss of support. Therefore these methods do not trigger the Moro reflex. The
nurse taps the biceps and the triceps with a reflex hammer to assess deep tendon reflexes. Looking at the infant's eyes with an ophthalmoscope tests the red reflex. Which parameter would the nurse be assessing in a newborn by using the Apgar scoring system 5 minutes after birth? 4 The Apgar scoring system helps determine the newborn's ability to adapt to extrauterine life. This scoring system is an assessment tool that helps examine the newborn's heart rate, muscle tone, and other signs. To assess the newborn's hearing ability, the nurse would conduct a hearing test but would not use the Apgar scoring system. Visual disorders can be assessed by
ophthalmoscopy. Therefore the Apgar scoring system does not help determine visual disorders in the newborn. To determine neuromuscular functioning, the nurse would test the stepping reflex and doll's eye reflex in the newborn. Sets with similar termsJarvis Chapter 28: The Complete Physical Assessmen…11 terms katieesil peds chapters 23, 2456 terms
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What does the examiner assess While examining the head and face of a patient?Face. Careful inspection of the face as a patient talks will reveal many factors. The examiner should look carefully for signs of trauma, previous facial surgery, eye swelling, or "bags under the eye," which might indicate fluid or allergic disorders. The quality of the skin can be quickly noted.
Which reflex would the nurse assess in a patient's eyes by using an ophthalmoscope?The red reflex is tested by viewing the pupil through an ophthalmoscope from a distance of approximately eighteen inches. A darkened room would be preferred as it is much easier to see the red reflex. To be considered normal, a red reflex should be identical in both eyes.
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