A nurse is assessing a toddler for developmental milestones.
At what age should a child be able to build a tower of six cubes?
18 months.
36 months.
24 months.
12 months.
The Correct Answer is C
Choice A rationale
At 18 months, a toddler is typically able to build a tower of only two to three cubes with coordination and intentional stacking. Building a tower of six cubes requires more developed fine motor skills and spatial reasoning.
Choice B rationale
By 36 months (3 years), most children can build a tower of more than six cubes, often reaching eight or more. This age reflects significant advancements in their fine motor control and hand-eye coordination.
Choice C rationale
At 24 months (2 years), a toddler typically develops the fine motor skills and hand-eye coordination necessary to build a tower of approximately six to seven cubes with relative stability. This milestone is a common indicator of developmental progress in this age range.
Choice D rationale
At 12 months (1 year), most infants are still developing their fine motor skills and are typically only able to stack one or two cubes, often more through trial and error than intentional building of a tall tower. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assessing for edema is an important nursing intervention in nephrotic syndrome because fluid retention due to decreased oncotic pressure is a common manifestation. However, preventing and monitoring for infection is a higher priority due to the immunosuppressed state of these children.
Choice B rationale
Providing a high-calorie diet is important to meet the increased metabolic needs associated with nephrotic syndrome and to compensate for energy loss. However, preventing infection takes precedence in nursing care.
Choice C rationale
Monitoring for signs of infection is the most important nursing intervention in a child with nephrotic syndrome. These children are at increased risk of infection due to protein loss (including immunoglobulins), edema compromising skin integrity, and potential immunosuppressive medications. Early detection and management of infection are critical to prevent serious complications. Normal temperature range is 97°F to 100.4°F (36.1°C to 38°C).
Choice D rationale
Encouraging high-protein snacks was a traditional recommendation but is now understood to potentially worsen proteinuria and is not the most important intervention. A moderate protein intake is generally recommended for children with nephrotic syndrome.
Correct Answer is D
Explanation
Choice D rationale
Hirschsprung disease is characterized by the absence of ganglion cells in a segment of the colon, leading to impaired peristalsis and difficulty passing stool. Monitoring bowel movements is crucial to assess the effectiveness of treatment, identify signs of obstruction, and guide further interventions.
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