A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?
a. Auscultate the lungs and heart while the infant is still sleeping.
b. Examine the infant's hips, because this procedure is uncomfortable.
c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach.
d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
ANS: A
When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be performed at the end of the examination.
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