A practical nurse (PN) is preparing to collect physical data on a 9-month-old infant who is currently resting quietly in a crib. To ensure accurate findings and minimize client distress, in which order should the PN perform the following data collection techniques? Arrange the actions in the appropriate sequence from first to last.
- 1Observe the chest and abdomen to count the resting respiratory rate.
- 2Auscultate the apical pulse for one full minute.
- 3Auscultate bilateral lung fields and abdominal bowel sounds.
- 4Palpate the abdomen, fontanelles, and extremities.
- 5Examine the pupillary response and assess the tympanic membranes.
Answer
The correct sequence for pediatric data collection is: observe the respiratory rate, auscultate the apical pulse, auscultate lungs and bowel sounds, palpate the body, and finally perform intrusive checks like pupillary and tympanic examinations.
In pediatric nursing, especially for infants and toddlers, data collection must progress from the least invasive to the most invasive procedure. Observing respirations requires no touch and must be done while the child is quiet. Auscultation of the heart and lungs involves gentle touch and should be done next. Palpation is more disturbing and follows auscultation. Finally, highly intrusive procedures such as examining the eyes with a light or ears with an otoscope will reliably cause distress and crying, so they are always reserved for the very end of the encounter.
Step-by-Step Solution
Key Concept
Pediatric Data Collection Principles