by Respiratory Therapy Zone | Neonatal and Pediatric Care

How to Perform a Neonatal or Pediatric Patient

Assessment?

A Patient Assessment refers to the ability of the medical professional to perform an initial
observance and examination of a patient in order to get a general idea of their current status.

This is fundamentally true, not only for adults but for infants and children as well. A typical
neonatal or pediatric patient assessment may include the following:

● Obtain vital sign measurement

● Gather Subjective Information
● Make therapeutic recommendations
● Evaluate the patient’s progress
● Recognize adverse reactions

Each patient is unique, therefore, each patient assessment may be unique as well.
Neonatal and Pediatric Patient Assessment Practice
Questions:

1. While attending to a neonatal patient in the neonatal intensive care unit (NICU), the
therapist notices that a transcutaneous electrode is affixed to the upper chest of the
neonate. What should the therapist do at this time?
The therapist should continue monitoring because the electrode is properly placed.
2. What is the Apgar scale?
It is a standard measurement system that looks for a variety of indications of good health in
newborns.
3. During a physical examination of a child’s chest, the therapist assesses increased tactile
fremitus over the patient’s right lower lobe. Which of the following conditions may cause
this physical finding?
Pulmonary consolidation.
4. Which of the following is the main physiologic factor responsible for deriving accurate
transcutaneous data?
Peripheral perfusion.

5. What is a normal heart rate for a neonate?

120–170 bpm.
6. Using the formula given in the text, the mean blood pressure (MAP) of a 30-week
gestation newborn should be at least what?
35 mmHg.
7. A 12-hour-old infant is experiencing respiratory distress, and the neonatologist orders a
heel stick to assess the infant’s oxygenation status. What action should the therapist take
at this time?
Inform the physician that the results from this procedure will not provide accurate information
about the patient’s oxygenation status.
8. Two pulse oximeters are placed on a newborn. One is on the right wrist and shows a
reading of 96% on room air, while the other one is placed on the left foot and shows a
reading of 85% on room air. This is suggestive of what?
Significant shunting through a patent (open) ductus arteriosus.
9. A respiratory therapist has been ordered to obtain a blood gas sample from a
non-intubated premature baby. After selecting the best site to obtain the sample, what
should the RT suggest to ameliorate the pain associated with the procedure?
Give a pacifier dipped in 24% sucrose.

10. Which of the following factors would adversely affect the correlation between arterial
puncture measurements and those from a capillary sample?
Hypotension.
11. While auscultating a young child’s thorax, the therapist hears bilateral fine crackles.
Which of the following conditions can produce these adventitious sounds?
Pulmonary edema.
12. Which of the following components compose the history of present illness section of a
patient’s medical history?
Aggravating or alleviating factors.
13. What is the most common invasive procedure to assess the fetal condition?
Amniocentesis.
14. Which of the following disorders can develop in neonates as a result of receiving
concentrations of oxygen that produce a high PaO2?
Retinopathy of Prematurity.
15. As the head of a neonate contaminated with meconium emerges at birth, the heart rate
monitor indicates 120 beats/minute, and the physician notices that the infant has good
muscle tone and a strong respiratory effort. What should the physician do at this time to
provide airway care?
Only routine monitoring of respiratory vital signs is needed at this time.
16. What is the APGAR score of a newborn with the following assessments: HR 80 bpm;
Cyanotic; Grimace; Some flexion; Respiratory Rate 0.
3
17. What is the main potential problem associated with the premature rupture of
membranes?
Fetal infection.
18. A pregnant woman at 30 weeks of gestation with premature rupture of membranes has
been admitted to the hospital with preterm labor. The physician has ordered
betamethasone. When does the maximal benefit of antenatal corticosteroid occur to
reduce RDS?
After 48 hours.
19. Which of the following pieces of information DO NOT represent components of patient
history for a new pediatric patient?
Occupational History.

20. The therapist has evaluated a neonate’s oxygenation status to be as follows: PaO2, 40
mm Hg, and SpO2 (oxygen saturation as determined by pulse oximetry), 80%. What should
the therapist do at this time?
An FiO2 sufficient to raise the SpO2 to 90% needs to be given.
21. A respiratory therapist notices that an infant presents with irregular areas of dusky skin
alternating with areas of pale skin. On the basis of this observation, which of the following
conditions should the therapist anticipate this patient is having?
Hypotension.
22. While percussing the thorax of a child during a physical examination, the therapist
hears a dull percussion note over the child’s right lung. Which of the following conditions
WOULD NOT cause this physical finding?
Pneumothorax.
23. When is surfactant developed?
It is developed 34 weeks in gestation.
24. What happens if there is not enough surfactant?
It will cause low lung compliance, so then the lungs can’t keep the alveoli open, which will
cause RDS.
25. What are important questions to ask about a neonate’s history?
The type of delivery, presence of meconium or risks of infection, Is the baby full term?, Is the
baby breathing or crying?, and Does the baby have good muscle tone?
26. How can you know if a baby has good muscle tone?
If they appear to be somewhat in a ball; you do not want them to be limp.
27. How often should you do the APGAR scale?
1 and 5 minutes.
28. What is a good goal of the APGAR scale?
7 by 5-10 minutes post birth.
29. What should the SpO2 do after birth?
It should increase by 5% each minute for 1st 5 minutes of life.
30. In general, how do neonates breathe?
They are obligate nose breathers. They have rapid shallow breaths to maintain their FRC.
31. What is the breathing pattern for a baby?
Rapid and fast with periods of apnea.
32. What are the breath sounds for neonates?
Bronchovesicular breath sounds. You mostly hear them on the expiratory phase.
33. What kind of suction would you use for babies?
Bulb suction for the mouth and nose.
34. What is the Larynx like in a pediatric airway?
It has a forward tilt.

35. What is the most narrow spot in a pediatric airway?

The glottis; it is narrow from coracoid cartilage.
36. What are babies blood pressures like at birth?
They usually start out being hypotensive.
37. When does blood pressure normalize in pediatric patients?
After 10 years it will be the same as adults.
38. What are common respiratory issues with pediatrics?
Cough, Runny nose, Ear pain, Sore throat, Fever, and Sputum production.
39. What are common symptoms of respiratory issues with pediatrics?
Wheezing, SOB, Chest pain/tightness, Lethargy, Irritability, Unresponsiveness, and Stridor.
40. What are signs of respiratory distress with pediatrics?
Grunting, Retractions, Nasal flaring, Tachypnea, Cyanosis, Abdominal breathing, Head bobbing,
and Respiratory Distress.
41. What are some good questions to think about when doing a pediatric assessment?
Gather their history, what is the chief complaint?, nutritional status, is it a new, seasonal,
chronic, or recurring issue?, and what is their family, social, or environmental history?
42. What do we not do that is normally part of a physical assessment with babies?
Palpation — we do not assess for vocal fremitus.
43. With a pediatric physical assessment, what should you look for on inspection?
Scoliosis, retractions, pectus carinatum (pigeon chest), pectus excavatum (sunken chest).
44. With a pediatric physical assessment, what should you look for during palpation?
Tactile rhonchi.
45. With a pediatric physical assessment, what should you look for during percussion?
If resonant, this is normal; If hyperresonant, there is air trapping and possibly a pneumothorax;
If dull, it’s atelectasis; and if there is consolidation, there may be a pleural effusion.
46. With a pediatric physical assessment, what should you look for during auscultation?
Listen to see if they are either clear, or they may exhibit crackles, rhonchi, stridor, or fine
crackles.
47. What is the most frequent blood test performed in newborn infants and why?
The blood glucose test. It is frequently performed because hypoglycemia can damage the
developing brain just as much as hypoxia. Identifying the levels is important to start treatment.

48. What are the causes of hypoglycemia in an infant?

Infection, hyperinsulinemia, and low glycogen stores.
49. What is the fundamental difference between newborn and adult PFT?
Their ability to cooperate.

50. What PFT volumes can be measured easily in newborns independent of their
cooperation?
(1) Their FRC (by closed system helium dilution or closed system nitrogen wash out), (2) Their
Thoracic Gas Volumes (TGV) (requires use of a plethysmography and measures all the gas in the
thoracic cavity), and their Crying Vital Capacity (done by measuring the tidal volume while the
infant is crying). The infant should be able to cry vigorously.
51. What type of x-ray films are most often used on infants?
AP films and Lateral chest films.
52. What are the indications for infant chest x-ray?
Unexplained tachypnea, cyanosis, abnormal breath sounds, malformation of the chest or
airway, sick appearance, and mechanically ventilated infants.
53. Why is airway assessment of a newborn infant on a ventilator much more difficult to
assess than an adult?
An infant has a short tracheal length (less than 10 cm) and an increased compliance of the chest
wall (chest rise); and bilateral air movement and sounds.
54. How is hemodynamic assessment easy and hard in an infant?
Cannulation of umbilical vessels allows easy venous and arterial access. (Cannulation of the
aorta and superior vena cava is easy). Pulmonary artery monitoring is difficult (due to right to
left shunting, PDA, PFA make cardiac output calculations difficult to assess).
55. What respiratory disease, common in young children is a viral disease typically
proceeded by cold symptoms, may present with fever, may have stridor in severe cases;
symptoms worsen when crying or upset, typically self-limiting but can require intubation?
Croup.
56. What respiratory disease, common in young children is a bacterial disease, typically
presents abruptly with drooling, dysphagia (difficulty swallowing), and respiratory distress;
Patient is usually febrile, with stridor and no cough; requires intubation?
Epiglottitis

57. What should you look for with palpation on a pediatric assessment?
Remember that palpation is not helpful in patients under 3 years old. Otherwise, you look for
the tracheal position, spinal abnormalities, pulses, capillary reflex, and tactile rhonchi.
58. Where should you get a pulse on a pediatric patient?
Feel for their brachial pulse. The pattern should be normal.
59. What should the capillary reflex be on a pediatric patient?
It should be less than or equal to 2 seconds.
60. When is percussion useful?
When the patient is older than 2 years of age.
61. What are adventitious breath sounds with pediatric patients?
Wheezes (rhonchi), crackles (rales), pleural rub, stridor, and decreased breath sounds.
62. What is the length of inspiration vs expiration with pediatric patients?
1:1

63. What is RDS?

It is respiratory distress caused by immature lungs and a lack of surfactant. The treatment is to
administer surfactant and assist in lung inflation and ventilation.
64. What is the most common respiratory emergency in children?
A lodged object in the airway.

65. What are symptoms of a lodged object in the airway?

Wheezing – heard around an object.
66. What parameter demonstrates the largest difference when capillary blood is compared
with arterial blood?
The PO2 does not correlate well.
67. What condition is associated with an infant that is born early in gestation?
RDS
68. What is a common cause of hypothermia in an infant?
Infection.
69. What effect does abdominal distention have on respiration?
It impedes diaphragm movement.
70. If an infant’s entire hemithorax “lights up” during transillumination, what does this
signify?
It means that there is a significant pneumothorax present.
71. A child presents to the ER with difficulty breathing and a harsh, barking cough. History
reveals a runny nose. What is the diagnosis?
Most likely, croup.
72. A 4-year-old presents to the ER with difficulty breathing, a dry cough, and audible
inspiratory and expiratory wheezing. The child was playing outside prior to the difficulty
breathing. It’s progressively worsening. What is the diagnosis?
Asthma.
73. Premature infants are susceptible to what?
Bronchopulmonary dysplasia.

74. Post-term infants are susceptible to what?

meconium aspiration, persistent pulmonary hypertension, perinatal asphyxia
75. What is indicated by the presence of retractions in a newborn?
Stiff lungs.
76. Nasal flaring is a cardinal sign of what in an infant?
Respiratory distress and increased work of breathing.
77. What is a congenital diaphragmatic hernia?
An absence or incomplete development of one of the hemidiaphragms that allow abdominal
organs to enter the thorax.
78. A lateral film done in a child with epiglottitis will show what?
It will show a swollen epiglottis blocking the upper airway that looks like a “thumb sign”.
79. In a child with croup, an AP neck radiograph showing a narrowed subglottic airway
looks like what?
It has the appearance of a “steeple sign”.
80. How is the airway secured in a patient with epiglottitis?
It is secured by intubation.
81. Infants with heart disease tend to have what?
Intercostal retractions on the sides of their bodies.
82. Infants with lung disease tend to have what?
Substernal and subcostal retractions toward the center of the body.
83. The fundamentals for assessing the infant and child are what?
A good history, a physical exam, and interpreting the lab work and radiographic information.
84. Infants that are born between 37 and 42 weeks of gestation are called what?
Term Infants.
85. Infants that are born fewer than 37 weeks of gestation are called what?
Preterm Infants or “preemies” (premature).
86. Infants born at 43 or more weeks of gestation are called what?
Post-term infants.
87. A person younger than 3 months old is called what?
A young infant.
88. A person between 12 months old to adolescent is called what?
A child.
89. A newborn baby up to 28 days is called what?
A neonate.
90. The prenatal assessment of the Fetus includes what?
(1) Fetal movement, (2) Biophysical profile (Reactive HR, Body Tone, Amniotic Fluid), (3)
Lecithin/sphingomyelin (L/S) ratio (2:1), surfactant and lung maturity, (4) Fetal monitoring
(Tachycardia, deceleration and late decelerations are signs of fetal distress in uterine
environment, (5) Non-Stress Tests (NST), (6) Monitors Heart Rate changes with fetal movement.
91. Information that may suggest perinatal asphyxia include what?
Late HR deceleration, Low biophysical score, Decreased fetal movement, Meconium (first feces
of an infant) in amniotic fluid, Long labor, and Abnormal Vaginal bleeding.
92. A simple quick and reliable means to assess and document the newborn’s status
immediately after birth is what?
The APGAR scale (Appearance, Pulse, Grimace, Activity, Respirations).
93. APGAR scores are checked at what times?
First at 1 minute, and then again at 5 minutes.
94. Bluish colorization of the hands and feet is called what?
Acrocyanosis.

95. An APGAR score of 7-10 is considered what?

Normal.
96. An APGAR score of 4-6 is considered what?
Moderate depression. This infant needs an added FiO2 with BVM ventilation.
97. An APGAR score of 0-3 indicates what?
Severe depression and there is a need for extensive medical resuscitation that may include
intubation and mechanical ventilation.
98. What are the events leading to neonatal death?
Late decelerations, Accelerations Disappear, Fetal breathing stops, Fetal movement ceases,
Fetal tone absent, and/or Still Born.
99. Hyperthermia in a newborn is what?
37.5 Celsius or 99.5 Fahrenheit.
100. Hypothermia in a newborn or infant is what?
36.5 Celsius or 97.7 Fahrenheit.
101. What is NTE?
It stands for Neutral Thermal Environment. It is the environment temperature at which the
infant’s metabolic demands and oxygen consumption are the least.
102. Why are newborns and infants more prone to excessive inward movement of the
chest?
Their chest is more compliant. They breathe rapidly and shallowly to help avoid retractions and
chest wall collapse.
103. What are all of the techniques of examination?
Inspection, Palpation, Auscultation, and Transillumination.
104. What is the most important portion of the examination?
Inspection.
105. How will respiratory distress manifest itself in a newborn?
The newborn will show signs of retractions (sue to more negative pressure in the pleural space),
nasal flaring (attempts to dilate airways to decrease airway resistance), and grunting (attempts
to increase the lung gas volume).
106. What is indicated by a capillary refill time longer than 3 seconds in an infant?
Decreased cardiac output.
107. Normal breath sounds for infants can be described as?
Bronchovesicular and harsher than adults.
108. A common disorder that mostly affects premature infants is what?
RDS and it occurs when their lungs are not fully formed to make enough surfactant.
109. In using transillumination, what suggests a normal lung in an infant?
When there is a small halo around the light source.

110. Leukocytosis in an infant is commonly an indication of what?

An increase in WBC’s (>15,000/mm3) and it’s normally due to the infant’s environment
(hyperthermia or crying) but can also indicate that an infection is present.
References
The following are the sources that were used while doing research for this article:

● Faarc, Walsh Brian Rrt-Nps Accs. Neonatal and Pediatric Respiratory Care. 5th ed.,
Saunders, 2018. [Link]
● —. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020. [Link]
● —. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017. [Link]
Disclosure: The links to the textbooks are affiliate links which means, at no additional cost to
you, we will earn a commission if you click through and make a purchase.