A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?
Falls when throwing a ball overhand
Goes up stairs with two feet on each step
Runs with a wide stance
Refers to self by name
The Correct Answer is D
A. It is expected for a 24-month-old to have some difficulty with coordination when throwing a ball.
B. Using both feet on each step when going upstairs is developmentally appropriate at this age.
C. Running with a wide stance is common in toddlers as they develop balance and coordination.
D. This is the correct answer. By 24 months, a toddler should begin using pronouns such as "I" or "me" instead of referring to themselves by name, indicating a possible language delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.
B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.
C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.
D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.
Correct Answer is C
Explanation
A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.
B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.
C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.
D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.
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