A 4-month-old presents to the clinic. When palpating the head the nurse notes an open posterior fontanel. Which additional finding would lead the nurse to suspect congenital hypothyroidism?

A. Children with DKA are more likely to exhibit fatigue, lethargy, or altered mental status rather than hyperactivity. Hyperactivity may be seen in early stages of mild hypoglycemia, but DKA involves significant metabolic derangements that usually depress CNS activity. Therefore, hyperactivity is not a characteristic manifestation of DKA.

B. DKA usually causes tachycardia due to dehydration and compensatory mechanisms to maintain perfusion. Hypovolemia reduces circulating blood volume, prompting the heart to beat faster to maintain cardiac output. Bradycardia is uncommon and may indicate severe electrolyte imbalance or late-stage shock rather than typical DKA presentation.

C. In DKA, dehydration is a major concern. Children typically present with warm, dry, flushed skin due to fluid loss, hyperosmolarity, and osmotic diuresis. Pale, clammy, or moist skin is more characteristic of hypoglycemia or acute shock from other causes, not DKA.

D. This is the most characteristic finding in DKA. Kussmaul respirations, which are deep and rapid breaths, develop as a compensatory mechanism for metabolic acidosis. The body attempts to "blow off" carbon dioxide to partially correct the acid-base imbalance. The acetone (fruity) odor results from the accumulation of ketone bodies (acetoacetate, β-hydroxybutyrate, and acetone) in the blood. These ketones arise from fat breakdown secondary to insulin deficiency. This manifestation is both specific and clinically significant, helping differentiate DKA from other conditions.

A. The preschool stage (ages 3–6 years) corresponds to Erikson’s stage of Initiative vs. Guilt, where children take initiative in play, imagination, and planning activities. Pretend play, such as planning a tea party, is a hallmark of this developmental stage. It demonstrates creativity, initiative, and the ability to direct their own activities, which shows age-appropriate psychosocial development.

B. Imitation is more characteristic of the toddler stage (Autonomy vs. Shame and Doubt). While preschoolers may still imitate, it is not the primary defining behavior of their Eriksonian stage.

C. Taking apart a toy to understand how it works reflects curiosity and problem-solving more typical of the school-age child (Industry vs. Inferiority), who is focused on mastery and understanding how things function.

D. Building a model requires higher-level fine motor skills, sustained attention, and structured task completion, abilities more aligned with the school-age period rather than preschool development.