NUR 5354 Exam 2 Questions With Complete Solutions
Abnormal pediatric cardiac findings
Fatigue during feeding, esp. diaphoresis
Central cyanosis (tongue, lips), especially during crying or
feeding
lethargy, irritability
Diastolic murmur, harsh or loud murmur (>grade 3), pansystolic
murmur, murmur with thrill or cyanosis or abnormal vital signs
Fixed split S2 (ASD), single S2 (severe TOF), loud P2
(pulmonary hypertension)
abnormal pediatric neurological findings
Asymmetrical limb movement or posturing (e.g., hemiparesis)
Weakness or flaccidity in any limb
Poor visual tracking or lack of blink reflex (CN II)
No response to loud sounds (CN VIII)
Hoarse cry, nasal regurgitation, weak gag reflex (CN IX, X)
Weak or absent suck reflex (CN V, VII, IX)
Moro/startle reflex
stimulus: loud noises or sudden movement
response: extend arms and legs; throw head and neck back
0-4 months, gone by 4-6 months
rooting reflex
,an infant's response in turning toward the source of touching that
occurs anywhere around his or her mouth
0-4 months, gone by 3-4 months
palmar grasp reflex
reflexive curling of the infant's fingers around an object that
touches its palm
0-4 months, gone by 4-6 months
plantar grasp reflex (babinski)
reaction to stimulation of the sole of the foot that causes the toes
of the feet to curl
0-8 months, gone by 8 months
Asymmetric tone neck reflex
turning infant's head to one side, that leg and arm will extend
while the opposite flexes
0-3 months, gone by 3 months
stepping reflex
Reflex that causes newborn babies to make little stepping
motions if they are held upright with their feet just touching a
surface
best visible by 4 days, dependent on infant development for
disappearance
positive support reflex
Weight placed on balls of feet of infant
Stiffening of legs and trunk into extension for 20-30 seconds
,0-2 months, gone by 6 months
parachute reflex
extension of both arms when infant is thrust downward in the
prone position
8 months, usually does not disappear
Landau reflex
Infant should attempt to raise the head and arch the back when
placed in a prone position
0-6 months
Galant reflex
Stroking along one side of the spine while newborn is face
down, causes lateral flexion of lower body toward stimulated
side
0-4 months, gone by 4 months
Breast exam techniques women
Inspect the breasts in 4 views - arms at sides, over head, pressed
against hips and leaning forward, assess nipples for size,
symmetry, color, contour, any discharge)
Palpate supine with pads of fingers in a vertical strip or radial
pattern, use gliding motion to not miss any areas of tissue
Palpate rectangular area extending from clavicle to
inframammary fold or bra line and midsternal line to posterior
, axilla and into axilla, examine the tail of the breast
Palpate lymph nodes (central, axillary, humoral, supraclavicular
and infraclavicular)
Abnormalities of breast women
redness (inflammation or infection)
Peau d'orange, dimples, flattening, change in nipple direction,
retraction, bloody discharge- cancer
Paget disease- Eczematous changes that are malignant (scaling,
rash or ulceration on nipple extending to areola)
breast pain
not concerning for cancer, although focal pain still needs to be
assessed
Medications that can cause tenderness include: hormones,
SSRIs, spironolactone, and digoxin
Breast Cancer Assessment tools
Gail Model- women over 50, Suitable for those with no or
limited family history, assumes regular mammogram screening
Claus Model- high risk women, incorporates detailed family
history, including both female and male first- and second-degree
relatives
BRCA 1 and 2- genetic testing, Applies to high-risk women,
Integrates detailed personal and family history for precise
mutation probability, can start with women in 20s
Breast Cancer screening recommendations
biennial for women 50-75 years
younger than 50- Discuss risks and benefits with the patient;
Abnormal pediatric cardiac findings
Fatigue during feeding, esp. diaphoresis
Central cyanosis (tongue, lips), especially during crying or
feeding
lethargy, irritability
Diastolic murmur, harsh or loud murmur (>grade 3), pansystolic
murmur, murmur with thrill or cyanosis or abnormal vital signs
Fixed split S2 (ASD), single S2 (severe TOF), loud P2
(pulmonary hypertension)
abnormal pediatric neurological findings
Asymmetrical limb movement or posturing (e.g., hemiparesis)
Weakness or flaccidity in any limb
Poor visual tracking or lack of blink reflex (CN II)
No response to loud sounds (CN VIII)
Hoarse cry, nasal regurgitation, weak gag reflex (CN IX, X)
Weak or absent suck reflex (CN V, VII, IX)
Moro/startle reflex
stimulus: loud noises or sudden movement
response: extend arms and legs; throw head and neck back
0-4 months, gone by 4-6 months
rooting reflex
,an infant's response in turning toward the source of touching that
occurs anywhere around his or her mouth
0-4 months, gone by 3-4 months
palmar grasp reflex
reflexive curling of the infant's fingers around an object that
touches its palm
0-4 months, gone by 4-6 months
plantar grasp reflex (babinski)
reaction to stimulation of the sole of the foot that causes the toes
of the feet to curl
0-8 months, gone by 8 months
Asymmetric tone neck reflex
turning infant's head to one side, that leg and arm will extend
while the opposite flexes
0-3 months, gone by 3 months
stepping reflex
Reflex that causes newborn babies to make little stepping
motions if they are held upright with their feet just touching a
surface
best visible by 4 days, dependent on infant development for
disappearance
positive support reflex
Weight placed on balls of feet of infant
Stiffening of legs and trunk into extension for 20-30 seconds
,0-2 months, gone by 6 months
parachute reflex
extension of both arms when infant is thrust downward in the
prone position
8 months, usually does not disappear
Landau reflex
Infant should attempt to raise the head and arch the back when
placed in a prone position
0-6 months
Galant reflex
Stroking along one side of the spine while newborn is face
down, causes lateral flexion of lower body toward stimulated
side
0-4 months, gone by 4 months
Breast exam techniques women
Inspect the breasts in 4 views - arms at sides, over head, pressed
against hips and leaning forward, assess nipples for size,
symmetry, color, contour, any discharge)
Palpate supine with pads of fingers in a vertical strip or radial
pattern, use gliding motion to not miss any areas of tissue
Palpate rectangular area extending from clavicle to
inframammary fold or bra line and midsternal line to posterior
, axilla and into axilla, examine the tail of the breast
Palpate lymph nodes (central, axillary, humoral, supraclavicular
and infraclavicular)
Abnormalities of breast women
redness (inflammation or infection)
Peau d'orange, dimples, flattening, change in nipple direction,
retraction, bloody discharge- cancer
Paget disease- Eczematous changes that are malignant (scaling,
rash or ulceration on nipple extending to areola)
breast pain
not concerning for cancer, although focal pain still needs to be
assessed
Medications that can cause tenderness include: hormones,
SSRIs, spironolactone, and digoxin
Breast Cancer Assessment tools
Gail Model- women over 50, Suitable for those with no or
limited family history, assumes regular mammogram screening
Claus Model- high risk women, incorporates detailed family
history, including both female and male first- and second-degree
relatives
BRCA 1 and 2- genetic testing, Applies to high-risk women,
Integrates detailed personal and family history for precise
mutation probability, can start with women in 20s
Breast Cancer screening recommendations
biennial for women 50-75 years
younger than 50- Discuss risks and benefits with the patient;
