A mother tells the nurse that it is difficult to get her 4-year-old child to bed at night. Which of the following should the nurse suggest that the mother do?

Sleep hygiene includes routines, behaviors, and environmental conditions that support consistent, high-quality sleep. For preschoolers, ages 3–5, the goal is to help them get 10–13 hours of sleep per 24 hours, including naps.

Rationale for correct answer:

3. Preschoolers thrive on consistency and routine. A predictable sequence, such as taking a bath, brushing teeth, reading a story, and then going to bed, helps signal to the child that it’s time to wind down. Over time, this ritual becomes a behavioral cue that prepares the body and mind for sleep.

Rationale for incorrect answers:

1. Offering a present or material reward can undermine intrinsic motivation and does not address the root cause of bedtime resistance. It may also promote a pattern where the child expects a reward for basic routines.

2. Playing a running game before bedtime is stimulating, not calming. Physical activity close to bedtime increases alertness and adrenaline, making it harder for the child to settle down and fall asleep.

4. Allowing late weekend bedtimes disrupts the child’s internal sleep-wake rhythm and makes weekday bedtime more difficult. Sleep routines should be consistent across all days to maintain healthy patterns.

Take home points

• Establishing a consistent, calming bedtime routine is the most effective strategy for preschoolers with sleep difficulties.
• Avoid stimulating activities before bed, opt for quiet time, stories, or gentle music instead.
• Material rewards should not be the basis for sleep compliance; focus on nurturing habits, not transactional behavior.
• Consistency is key, routine sleep and wake times help regulate the child's biological clock and improve overall behavior and mood.

Visual acuity refers to the clarity or sharpness of vision. Visual acuity improves with age, reaching 20/20 by approximately age 6–7. Early detection of vision problems is important to prevent conditions like amblyopia, which can be treated more effectively when caught early.

Rationale for correct answer:
3. At age 4, 20/40 vision is developmentally normal. This means the child can see at 20 feet what a person with perfect vision sees at 40 feet. It reflects typical visual development at this age.

Rationale for incorrect answers:

1. 10/10 is not a standard measurement in vision testing and is not used clinically in the U.S.

2. 20/20 vision is ideal but not expected for most 4-year-olds. While some may achieve it, it is more typical for older children, around 6 years and above.

4. 40/40 is not a valid or recognized measure of visual acuity. Standard measurements use 20 as the baseline.

Take home points

• 20/40 is normal visual acuity for a 4-year-old, with gradual improvement expected as the child grows.
• Routine vision screening begins in the preschool years to identify early issues.
• Nurses should recognize age-based norms to properly evaluate developmental progress and guide parental expectations.
• Referral is needed if visual acuity is worse than age norms or if there's evidence of strabismus or other visual concerns.