NUR 425 Pediatrics Exam 1 UPDATED ACTUAL Questions and CORRECT Answers
HR awake: 100-180
HR sleeping: 75-160
Infant VS (1-12 mo)
RR: 30-60
hypotension systolic: <70
HR awake: 100-150
HR sleeping: 75-150
Toddler VS (1-3 years)
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
HR awake: 60-150
HR sleeping: 60-90
Preschool VS (3-6 years)
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
HR awake: 60-110
HR sleeping: 60-90
School age VS (6-10 years)
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
HR awake: 50-110
HR sleeping: 50-90
Pre-teen/Teenager VS (>10 yrs)
RR: 12-16
hypotension systolic: <90
1. appearance: tone, interactiveness, consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions,
nasal flaring
Pediatric Assessment Triangle
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
, 1. development: dependent on parent, will look to parents for security and reacts to
parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo:
Assessments and communication for infant
best in parent arms or laying on parent lap (parent active part of exam, asses parent
(up to 12 mo)
attachment)
4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic
procedures last (eyes, ears, mouth)
stranger anxiety will set in around 6 mo
1. development: utilizes parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab
Assessment and communication for
toddlers (1-3 yrs) 3. position: best to begin in parent arms or lap; assess on parent first and then child
4. sequence: warm child up to you first (toys, play), let them touch equipment before
use, first attempt to auscultate heart lung abdomen, invasive assessments last, may
cooperate well at first due to curiosity
1. development: increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab, if timid try averting eye contact
Assessment and communication for
3. position: child may want to begin on parents lap or holding hand, assess on parent
preschoolers (3-5 yrs)
first then child
4. sequence: use play and toys to become acquainted and non-threatening; inspect
body through counting fingers with minimal contact; introduce equipment through
play (let them feel/touch equipment), auscultate ASAP
1. development: seeking autonomy; exploring (self exploration/stimulation common);
still prefers parent close
2. interview: include child in interview/subjective info; the kids like to answer
Assessment and communication for school
questions about themselves
age (5-12 yrs)
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
1. development: autonomy important
2. interview: let patient speak for themselves; clarify questions at the end; allow
parents to add at the end
Assessment and communication for
3. positioning: sitting/alone; may want parent to leave the room during physical
adolescent (12-18 yrs)
assessment
4. sequence: head to toe assessment; genital area last
confidentiality unless safety is a concern
HR awake: 100-180
HR sleeping: 75-160
Infant VS (1-12 mo)
RR: 30-60
hypotension systolic: <70
HR awake: 100-150
HR sleeping: 75-150
Toddler VS (1-3 years)
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
HR awake: 60-150
HR sleeping: 60-90
Preschool VS (3-6 years)
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
HR awake: 60-110
HR sleeping: 60-90
School age VS (6-10 years)
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
HR awake: 50-110
HR sleeping: 50-90
Pre-teen/Teenager VS (>10 yrs)
RR: 12-16
hypotension systolic: <90
1. appearance: tone, interactiveness, consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions,
nasal flaring
Pediatric Assessment Triangle
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
, 1. development: dependent on parent, will look to parents for security and reacts to
parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo:
Assessments and communication for infant
best in parent arms or laying on parent lap (parent active part of exam, asses parent
(up to 12 mo)
attachment)
4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic
procedures last (eyes, ears, mouth)
stranger anxiety will set in around 6 mo
1. development: utilizes parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab
Assessment and communication for
toddlers (1-3 yrs) 3. position: best to begin in parent arms or lap; assess on parent first and then child
4. sequence: warm child up to you first (toys, play), let them touch equipment before
use, first attempt to auscultate heart lung abdomen, invasive assessments last, may
cooperate well at first due to curiosity
1. development: increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab, if timid try averting eye contact
Assessment and communication for
3. position: child may want to begin on parents lap or holding hand, assess on parent
preschoolers (3-5 yrs)
first then child
4. sequence: use play and toys to become acquainted and non-threatening; inspect
body through counting fingers with minimal contact; introduce equipment through
play (let them feel/touch equipment), auscultate ASAP
1. development: seeking autonomy; exploring (self exploration/stimulation common);
still prefers parent close
2. interview: include child in interview/subjective info; the kids like to answer
Assessment and communication for school
questions about themselves
age (5-12 yrs)
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
1. development: autonomy important
2. interview: let patient speak for themselves; clarify questions at the end; allow
parents to add at the end
Assessment and communication for
3. positioning: sitting/alone; may want parent to leave the room during physical
adolescent (12-18 yrs)
assessment
4. sequence: head to toe assessment; genital area last
confidentiality unless safety is a concern
