Practice Question
A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. use all the steps.)
Answer Choices:
Rationale:
Inspection
🟠Inspection must always occur first because any touch or manipulation can alter the abdomen’s appearance or affect bowel movement patterns.
🟠The nurse observes contour, symmetry, skin integrity, visible movements, and distention, all of which must be assessed before disturbing the area.
🟠Children may have subtle abdominal changes that are best seen when the abdomen is undisturbed.
🟠Early observation helps identify guarding, masses, hernias, or visible peristalsis without interference.
🟠Performing inspection first ensures that baseline visual information is accurate before proceeding to other assessment steps.
Auscultation
🟠Auscultation must precede palpation because touching the abdomen can stimulate or suppress bowel sounds, altering true findings.
🟠Listening early allows the nurse to assess frequency, presence, and quality of bowel sounds without external influence.
🟠Children have more sensitive gastrointestinal activity; accurate auscultation is crucial in ruling out ileus, obstruction, or hyperactivity.
🟠The nurse also listens for vascular sounds, which could be masked if palpation is done first.
🟠This placement protects the integrity of objective bowel sound assessment.
Superficial Palpation
🟠Superficial palpation is performed before deeper palpation to assess tenderness, temperature, turgor, and muscle tone without causing discomfort or spasm.
🟠Gentle touch allows the nurse to identify areas of pain, which helps guide deeper assessment safely.
🟠Children may tighten muscles reflexively, so starting lightly reduces guarding and improves accuracy.
🟠This step identifies superficial abnormalities such as skin sensitivity, mild distention, or early organ enlargement.
🟠Superficial palpation prepares the nurse to safely proceed to deeper techniques.
Deep Palpation
🟠Deep palpation is performed last because it carries the highest risk of discomfort, especially in pediatric clients.
🟠Pressing firmly can alter bowel sounds, cause pain, and increase abdominal guarding, so it must come after all non-invasive steps.
🟠This technique assesses organ size, masses, and deeper tenderness, requiring prior knowledge of areas already sensitive on light palpation.
🟠Performing it last prevents distortion of earlier assessment findings, especially auscultatory results.
🟠Deep palpation completes a safe, systematic abdominal exam consistent with pediatric assessment standards.
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This question is from Custom: Peds Assessment one 2025 which contains 53 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4