A practical nurse is assisting with a well-child visit for a 12-month-old infant at a community health clinic. To minimize stranger anxiety and ensure accurate data collection, in what sequence should the nurse perform the following actions? Arrange the procedures from least invasive to most invasive.
- 1Observe the infant interacting with the caregiver to assess psychosocial and motor milestones.
- 2Auscultate the apical pulse and breath sounds while the infant rests quietly.
- 3Palpate the abdomen for expected softness and absence of masses.
- 4Examine the tympanic membranes using an otoscope.
- 5Administer the prescribed subcutaneous varicella immunization.
Answer
The correct sequence prioritizes non-invasive observation first, followed by quiet auscultation, then palpation, delaying highly distressing procedures like the ear exam and painful immunizations until the very end.
In pediatric health promotion visits, the physical assessment sequence must be altered to accommodate the child's developmental stage. For an infant with expected stranger anxiety, the nurse must progress from least invasive to most invasive. Observation is completely non-invasive, auscultation requires quiet but is painless, palpation is tactile, the ear exam is highly restrictive and distressing, and immunizations are painful. Reversing this order ruins baseline vital signs and assessment accuracy.
Step-by-Step Solution
Key Concept
Pediatric Health Assessment Sequence
Estimated Time:1m 30s