Assessment

Assessment is the largest domain on the CPN exam: 35 percent of scored items, or 53 questions. Every plan the nurse makes stands on this foundation, and the exam tests not just what to assess but how — with tools matched to the child's developmental and cognitive level, with the family as the constant in the child's life, and with safety woven through every encounter. Growth and development remain the common thread: normal varies by age, and the nurse's first job is knowing what normal looks like.

II.a. Physical assessment

1. Obtain health history

The pediatric health history is gathered from the parent or caregiver for infants and young children, and from both the child and the parent as the child matures. Adolescents should be interviewed alone for sensitive topics such as sexual activity, substance use, and mental health, with confidentiality explained up front. The history covers the chief complaint in the family's own words, the history of present illness (onset, character, timing, aggravating and relieving factors), past medical and surgical history, birth history including gestational age and birth weight, immunization status, every current medication with dose and frequency including over-the-counter products and supplements, allergies with the specific reaction described, and family medical risk factors such as asthma, diabetes, heart disease, and genetic conditions. The social history — who lives in the home, who cares for the child, school or daycare attendance, tobacco smoke exposure, pets, and the home environment — is part of every history, not an extra.

2. Assess growth parameters and developmental milestones

At every encounter the nurse measures weight, length or height, and head circumference in children under 2 years, then plots each on the correct chart: the WHO growth standards from birth up to 2 years, the CDC charts from 2 years on. Body mass index is calculated and plotted from age 2^[1]. A key anchor for interpretation: an infant should double birth weight by 4 to 6 months^[2]. Developmental milestones are checked against the CDC's "Learn the Signs. Act Early." checklists at each well visit — for example, walking without holding on is an 18-month milestone, so a 12-month-old who cruises furniture but does not walk alone is developing normally^[3]. The nurse watches for red flags rather than memorizing every milestone: loss of a previously attained skill at any age, and weight that falls across more than two major percentile lines, both of which trigger prompt evaluation^{[3, 4]}.

3. Perform physical assessment using a developmental approach

The examination is sequenced from least to most invasive, and the approach bends to the child's age. Infants and toddlers are examined on the parent's lap whenever possible, with play, song, and familiar objects enlisted as allies; the painful, frightening, or intrusive parts — ears, mouth, genitalia — come last. Preschoolers respond to brief explanations and choices that are real ("should I listen to your heart first or look in your ears first?"). School-age children can follow a head-to-toe sequence and appreciate privacy. Adolescents are examined with a gown, draping, and a chaperone, with sensitive areas addressed matter-of-factly. The newborn examination includes the hips: in the Ortolani maneuver the hip is gently abducted and a clunk means a dislocated hip is relocating, while in the Barlow maneuver the hip is adducted — with posterior force in some techniques, though the AAP recommends against it — and a clunk means it can be dislocated; asymmetric skin folds, by contrast, are also found in 27% of infants without dysplasia^[5].

4. Assess pain using developmentally and cognitively appropriate tools

Pain assessment starts from a simple rule: self-report is the gold standard whenever the child can provide it. When the child cannot self-report, the nurse uses a validated behavioral or composite tool matched to age and setting. The pediatric pain-assessment procedure used here assigns tools as follows: newborns to 2 months are assessed with NIPS; infants in the intensive care nursery with NPASS; children from 2 months up to 4 years with FLACC; children 4 through 8 years with the FACES scale; and children 9 years and older with the numeric rating scale^[6]. Nonverbal children who are intubated or sedated are assessed with FLACC, as are preverbal or developmentally delayed children who cannot self-report, and before a painful procedure the nurse assumes pain is present rather than absent^[6]. Pain reassessment following each intervention is part of the plan^[6].

5. Assess nutritional status

Nutritional assessment combines the diet history — a 24-hour recall or food frequency, breastfeeding or formula type and amounts, timing of complementary foods — with the growth data from the chart. Weight faltering, or failure to thrive, is defined by criteria that include weight for age below the fifth percentile, a decrease of more than two major percentile lines, or weight below 80 percent of the median weight for height^[4]; because the underlying reason is often inadequate caloric intake with non-organic causes, evaluation draws in an interprofessional team including nutrition, behavioral health, and social work^[4]. The nurse also screens for risk factors that change what to look for: exclusive breastfeeding without vitamin D supplementation, restrictive diets, food insecurity, and chronic illness that raises metabolic demand.

6. Assess functional status

Functional assessment asks what the child can actually do, day to day, at an age-appropriate level: self-care such as feeding, dressing, toileting, and hygiene; ambulation and mobility; vision and hearing; and participation in school and play. For children with chronic conditions or disabilities the nurse documents baseline function precisely, because a change from baseline is often the earliest sign of deterioration, and identifies adaptive equipment, therapies, and school accommodations the child uses. Vision and hearing screening matters at every age — a child labeled inattentive or delayed may simply not see the board or hear the teacher.

7. Recognize and anticipate trends and variables that may lead to improvement or deterioration of physiologic status

Single vital-sign values mean less than trends: the nurse who watches the trajectory of heart rate, respiratory rate, blood pressure, oxygen saturation, work of breathing, perfusion, and mental status catches deterioration early. Pediatric early warning scores formalize this habit, but the principle is older — know the normal ranges for the age, and act on the direction of change. Blood pressure is measured annually in children and adolescents 3 years and older, and at every health care encounter for children with obesity, renal disease, or diabetes, those taking medications known to raise blood pressure such as stimulants, and those with a history of aortic arch obstruction or coarctation^[7]. Variables that signal movement in the wrong direction include increasing work of breathing, delayed capillary refill, narrowing pulse pressure, new irritability or lethargy, and decreasing urine output — each a cue to escalate, not to watch and wait.

8. Recognize and screen for signs and symptoms of addiction and withdrawal

The nurse screens across three very different scenarios. In the newborn with prenatal substance exposure, neonatal abstinence signs include irritability, tremors, a high-pitched cry, poor feeding, and loose stools, and the history must be taken without judgment so the mother discloses use. In the child receiving prolonged sedation or opioid infusions in intensive care, medically induced dependency is expected, and weaning is planned rather than abrupt. In the adolescent, screening for substance use is done privately with a validated tool, and withdrawal signs — agitation, diaphoresis, tremor, nausea — are recognized as medical findings to manage, not behaviors to punish.

9. Assess for risks to safety

Safety assessment is tailored to what the child's developmental stage makes dangerous: the infant's sleep environment and the toddler's access to water, stairs, and small objects; the school-age child's helmet, pedestrian, and sports safety; the adolescent's driving, substance use, and firearm access. In the health care setting the nurse verifies identity with two identifiers, checks allergies before every medication, and keeps side rails, call bells, and developmentally appropriate supervision matched to the child — not the room number. Environmental questions belong in the history too: chipping or peeling paint in a home built before 1978 and water from lead pipes are recognized lead sources^[8].

10. Assess for physical signs of maltreatment or neglect

The nurse examines with maltreatment in mind, not in suspicion of every family but with the pattern knowledge that protects children. Concerning findings include bruises or injuries in a non-mobile infant, injuries in multiple stages of healing, pattern marks that mirror objects, burns with clear lines of demarcation such as stocking-glove distributions, and a history that does not fit the injury or that changes between tellings. Neglect leaves its own signs: persistent poor hygiene, untreated medical or dental conditions, and the growth faltering described above. Nurses are among the professionals mandated to report — when the nurse suspects or has reason to believe a child has been abused or neglected, a report is made, and the nurse documents objectively what was seen and heard, without drawing legal conclusions in the record^[9].

II.b. Psychosocial assessment

1. Assess the child's environments

The nurse assesses every environment the child inhabits — home, school, neighborhood, and the health care setting itself — for how well it meets the child's developmental, cognitive, and physical needs. At home that means supervision, sleep space, and safety; at school it means attendance, performance, peer relationships, and whether vision, hearing, or learning needs are accommodated; in the hospital it means whether the setting supports sleep, play, family presence, and the child's need for control. A child who is "difficult" in one setting and thriving in another is giving assessment data about the setting, not just about the child.

2. Identify cultural and spiritual influences that impact child and family health care practices

Culture and spirituality shape what families believe about illness, who makes decisions, what treatments are acceptable, which foods are eaten and when, and how grief and dying are handled. The nurse asks rather than assumes: what matters most to your family in caring for your child, are there practices we should accommodate, and who should be part of decisions. A professional interpreter is used whenever language differs — never a child or a family member pressed into the role — and the nurse distinguishes between respecting a belief and abandoning the duty to protect the child, escalating through ethics and leadership when the two collide.

3. Assess impacts of adverse childhood experiences (ACEs) and social determinants of health

Adverse childhood experiences — abuse, neglect, and household dysfunction such as violence, mental illness, or substance use in the home — are common and consequential: about one in six adults experienced four or more types of ACEs, the toxic stress they produce can change brain development and the body's stress response, and ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood^[10]. Alongside ACEs the nurse assesses social determinants of health: socioeconomic status, housing stability, food security, displacement, and racial inequalities that shape access and outcomes. Screening is done with sensitivity and with resources ready — asking about trauma without a path to help retraumatizes.

4. Assess family dynamics

The nurse observes how the family functions as a system: its structure and who holds which roles, how members communicate, how decisions get made, how affection and conflict are expressed, and how parenting is shared or contested. Caregiver stress, maternal depression, intimate partner violence, and sibling relationships all belong in this assessment, gathered through observation and gentle direct questions. Family dynamics are assessed without taking sides and without pathologizing cultural differences in family organization.

5. Assess general state of mental and emotional health

Every encounter is a chance to notice depression, anxiety, self-harm, and suicide risk — withdrawal, changes in sleep or appetite, declining school performance, and statements of worthlessness or hopelessness. For suicide screening the Ask Suicide-Screening Questions tool begins with four brief questions, and any "yes" triggers the acuity question about current thoughts of killing oneself; a current wish to die is an acute positive screen requiring a STAT safety and full mental health evaluation, with the patient kept in sight, not allowed to leave until evaluated, and dangerous objects removed when possible^[11]. A non-acute positive screen still requires a brief suicide safety assessment, not dismissal^[11].

6. Assess for risk-taking behaviors

Substance use, sexual activity, and dangerous driving are assessed directly and privately with the adolescent, in language that is nonjudgmental and developmentally appropriate. The nurse asks about peers and context as well as behavior, because risk-taking clusters, and connects screening to action: counseling, contraception, substance use resources, and safety planning. The same privacy that makes disclosure possible obliges the nurse to explain its limits — imminent danger to self or others, including abuse, must be disclosed and reported.

7. Assess for risk factors and psychosocial indicators of maltreatment or neglect

Beyond physical signs, the nurse watches for psychosocial indicators: family stress and substance abuse, intimate partner violence, social isolation, a child who is withdrawn or fearful, and inconsistencies in the history between caregivers or across tellings. Human trafficking risk factors — running away, an older controlling companion, unexplained absences or resources — are assessed in the adolescent with private, trauma-informed questioning. A caregiver who offers conflicting, unconvincing, or no explanation for an injury is one such indicator^[12]. As with physical signs, suspicion triggers a report, and the reporter does not have to prove that abuse occurred^[9].

8. Recognize acute stressors impacting the child and family, and assess responses and coping skills

Hospitalization, painful procedures, a new diagnosis, a parent's job loss or divorce — acute stressors land on children through the filter of development. The nurse watches how the child and family respond: regression, clinginess, sleep disturbance, acting out, withdrawal, somatic complaints, or a parent's anger at the team that is really fear wearing a disguise. Naming the stressor and the response out loud, without judgment, is itself an intervention, and it guides what support to offer next.

9. Identify the child's and family's adjustment to acute and chronic conditions

Adjustment is not a single moment but a moving process, and families revisit grief with each new developmental stage or disease milestone. The nurse assesses where the child and family are: shock and disbelief, anger or guilt, bargaining with treatment, gradual adaptation — and recognizes chronic sorrow, the recurrent grief parents of children with chronic conditions or disabilities experience. Siblings' adjustment is assessed deliberately, because their needs are the easiest to overlook and their distress often surfaces as behavior problems at school or home.

10. Assess coping mechanisms of child, siblings, and caregivers

The nurse distinguishes coping that helps from coping that harms: problem-solving, seeking information, humor, spiritual practices, and asking for support on one side; avoidance, denial that blocks needed care, substance use, and aggression on the other. Each family member is assessed individually — the stoic parent may be coping well or may be quietly drowning — and strengths are named explicitly so the family can lean on them. When coping fails, the nurse connects the family to counseling, support groups, child life, or spiritual care rather than labeling the family difficult.

11. Determine the child's and family's understanding of the health or disease process

Before teaching, the nurse finds out what the learner already believes: what do you understand about your child's condition, what have you been told so far, what worries you most. The teach-back method then closes the loop — "I want to be sure I explained clearly; can you tell me in your own words how you'll give this medicine?" — which tests the teaching, not the learner. Explanations are matched to developmental level and health literacy, medical jargon is translated, and understanding is reassessed over time because it changes with stress, fatigue, and disease progression.

12. Assess barriers to adherence with the therapeutic regimen

Nonadherence is rarely defiance; it is usually a barrier the nurse has not found yet. The nurse assesses motivation and belief in the treatment, access and cost, transportation, health literacy and language, cultural or spiritual conflicts with the regimen, the sheer complexity of what is being asked, and side effects the family never mentioned. The most useful question is often the simplest: "What makes it hard to do this every day?" Asked without judgment, it surfaces the real obstacle — the teenager embarrassed to use an inhaler at school, the parent who cannot read the dosing syringe, the family choosing between medication and groceries.

13. Identify educational needs of child and family

From the assessment of understanding and barriers flows the teaching plan: what the child and family need to learn about the plan of care, its priorities, and discharge planning. Needs are prioritized — survival skills first, such as recognizing deterioration and knowing when to call — and teaching is paced, repeated, and documented with the learner's response. Discharge planning begins at admission, not the day before, and the nurse confirms that education has landed before the family leaves, because the most elegant plan fails if the family cannot carry it out at home.

Key numbers

• Head circumference: part of growth assessment up to 2 years of age^[13].
• BMI: calculated from age 2; overweight is 85th to below 95th percentile, obesity at or above 95th^{[1, 14]}.
• Blood pressure: annually from age 3; at every encounter with obesity, renal disease, diabetes, aortic arch obstruction, or BP-raising drugs^[7].
• Pain tools: NIPS (newborn to 2 months), NPASS (intensive care nursery), FLACC (2 months up to 4 years; nonverbal or sedated), FACES (4 through 8 years), numeric rating (9 years and older)^[6].
• Weight faltering: weight for age below the 5th percentile, or a fall of more than 2 major percentile lines^[4].
• Milestones (CDC checklists): sits without support at 9 months; a few steps alone and one or two words at 15 months; walks without holding on and 3+ words at 18 months; two words together at 2 years; lost skills — don't wait^[3].
• Lead: no safe blood lead level; CDC reference value 3.5 µg/dL^[8].
• Autism signs: avoids eye contact; no response to name by 9 months^[15].
• ASQ: acute positive means STAT safety evaluation; the patient cannot leave and is kept in sight^[11].
• ACEs: 1 in 6 adults had 4 or more; preventing ACEs could cut adult depression by as much as 44%^[10].

Sources cited in this excerpt

1. Use and Interpretation of the WHO and CDC Growth Charts for Children from Birth to 20 Years in the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/growth-chart-training/media/pdfs/2025/03/Use-of-WHO-CDC-Growth-Charts_508.pdf (via web.archive.org)
2. Normal growth and development: MedlinePlus Medical Encyclopedia. https://medlineplus.gov/ency/article/002456.htm
3. Milestone Checklists. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/actearly/milestones/
4. Failure to Thrive - StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459287/
5. Developmental Dysplasia of the Hip - StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK563157/
6. Pain Assessment and Management in Infants, Children and Adolescents (Pediatric/Neonatal). UCSF Medical Center, Department of Nursing. https://www.childkind.org/pain-assessment
7. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. American Academy of Pediatrics. https://publications.aap.org/pediatrics/article/140/3/e20171904/38358/Clinical-Practice-Guideline-for-Screening-and
8. About Childhood Lead Poisoning Prevention. https://www.cdc.gov/lead-prevention/about/index.html
9. Mandatory Reporting of Child Abuse and Neglect. https://www.childwelfare.gov/resources/mandatory-reporting-child-abuse-and-neglect/
10. Preventing Adverse Childhood Experiences. https://www.cdc.gov/vitalsigns/aces/index.html
11. Ask Suicide-Screening Questions (ASQ) Suicide Risk Screening Tool. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
12. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. https://www.childwelfare.gov/resources/what-child-abuse-and-neglect-recognizing-signs-and-symptoms/
13. Use and Interpretation of the WHO and CDC Growth Charts for Children from Birth to 20 Years in the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/growthcharts/who-charts.htm
14. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. American Academy of Pediatrics. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and
15. Signs and Symptoms of Autism Spectrum Disorder. https://www.cdc.gov/autism/signs-symptoms/index.html