A 22-month-old toddler is walking into the examination room independently in front of the toddler’s mother. Which method should the nurse plan to use to weigh the child?
A standing scale should be used because the toddler is able to stand independently.
Weigh using an infant scale because this is the method for all infants until the age of 2 years.
Ask the mother which would be best for the child.
Have the mother weigh herself and then weigh herself holding her child. Then subtract the mother’s weight from the combined child and mother’s weight.
Have the mother weigh herself and then weigh herself holding her child. Then subtract the mother’s weight from the combined child and mother’s weight.
The Correct Answer is A
Weight assessment in children is the process of measuring and interpreting a child’s body weight in relation to age, height, and sex to evaluate growth, nutritional status, and overall health. It’s a key part of pediatric care and helps identify undernutrition, overweight, or obesity early on.
Rationale for correct answer:
A. If a toddler can stand alone, a standing scale provides an accurate weight and is more comfortable for the child. At 22 months, many children have the stability to stand still briefly for weighing.
Rationale for incorrect answers:
B. Infant scales are generally used for babies and younger toddlers who cannot stand unsupported; by this age and developmental stage, a standing scale is suitable.
C. While involving the mother in care decisions is important, the method of weighing is based on developmental capability, not caregiver preference.
D. The “subtracting method” is less accurate and is typically used only when the child cannot stand and an infant scale is unavailable.
Take home points
- Choose the weighing method based on developmental ability, not strictly on age.
- Standing scales are appropriate for toddlers who can stand still without assistance.
- Accurate anthropometric measurements are key for growth monitoring and detecting developmental or nutritional concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Effective pediatric assessmentincludes not only age-appropriate interaction but also a solid understanding of developmental physiology. Therapeutic communication complements accurate assessment by helping nurses explain procedures and results in ways appropriate to the child’s age and developmental stage.
Rationale for correct answer:
A. Accurate interpretation of BPin pediatric patients requires an understanding of age-specific norms. Blood pressure gradually increases with age, so a reading of 95/58 mm Hg may be normal for a toddler but hypotensive for a school-age child. Using correct reference values ensures appropriate identification of hypotension or hypertension.
Rationale for incorrect answers:
B. While cuff size is crucial, it should be based on limb circumference, not length. The cuff bladder width should be approximately 40% of the arm circumference, and the length should cover 80–100% of the arm. Using the wrong size can yield inaccurate readings.
C. A child is normotensiveif their BP is below the 90th percentilefor age, sex, and height. Readings between the 90th and 95th percentiles are considered prehypertensive, while readings above the 95th percentile suggest hypertension.
D. In conditions like coarctation of the aorta, upper-extremity BP is higherthan lower-extremity BP. A lower BP in the legscompared to the arms is a classic sign of this condition, not the reverse.
Take home points
- Know age-specific BP norms to detect abnormalities in pediatric clients.
- Use the correct cuff size, measured by arm circumference, for accurate readings.
- Interpret BP percentiles properly: Normal is below the 90th percentile.
- Compare upper and lower extremity BPs in suspected cardiac conditions like coarctation of the aorta, not aortic stenosis.
Correct Answer is D
Explanation
A physical examination in childrenis a systematic evaluation of a child’s body systems to assess their health, growth, and development. It’s tailored to the child’s age, developmental stage, and presenting concerns, and it plays a vital role in early detection of illness and developmental delays.
Rationale for correct answer:
D.Developmental ageguides how the nurse communicates, sequences the exam, and engages the child. For toddlers, this means using simple language, allowing parental presence, and starting with least invasive assessments first.
Rationale for incorrect answers:
A.While parental presencecan provide comfort and reduce anxiety, it is not the primary consideration; the developmental approach to the exam comes first.
B.A firm tonemay increase fear and resistance in toddlers; calm, gentle, and encouraging communication is more effective.
C.Waiting until the child is “ready”may not be practical in a hospital setting, and some cooperation can be gained through distraction and play without unnecessary delays.
Take home points
- Pediatric assessments should always be tailored to developmental age for accuracy and cooperation.
- Toddlers respond best to gentle communication, parental presence, and strategic sequencing of the exam.
- Understanding developmental milestones helps nurses choose the right techniques for assessment and interaction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.