A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

Superficial scrapes on the toddler's lower legs

Circular burns on the soles of the toddler's feet

Irregular area of blue pigmentation over the toddler's sacrum

Single bruise on the toddler's forearm

Answer and Explanation

The Correct Answer is B

A. Superficial scrapes on the toddler's lower legs: These are common in toddlers due to normal play and exploration.
B. Circular burns on the soles of the toddler's feet: Circular burns, especially in unusual areas like the soles, are a hallmark sign of intentional injury and potential abuse.
C. Irregular area of blue pigmentation over the sacrum: This is likely a Mongolian spot, a benign and common finding in children of certain ethnicities.
D. Single bruise on the toddler's forearm: This is not necessarily indicative of abuse, as toddlers frequently sustain minor injuries from routine activities.

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Correct Answer is D

Explanation

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.

A. Restrict the child's potassium intake. B. Provide quiet activities for the child. C. Weigh the child once a week. D. Administer acetaminophen to the child daily.

Correct Answer is B

Explanation

A. Restrict the child's potassium intake. Potassium restriction is not typically required unless hyperkalemia is present.
B. Provide quiet activities for the child. Edema can cause fatigue, and quiet activities help conserve energy and reduce strain.
C. Weigh the child once a week. Daily weight monitoring is critical to track fluid retention or loss.
D. Administer acetaminophen to the child daily. Acetaminophen is not routinely required unless there is a specific indication, such as fever or pain.

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A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

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