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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?

A.

Superficial scrapes on the toddler's lower legs

B.

Circular burns on the soles of the toddler's feet

C.

Irregular area of blue pigmentation over the toddler's sacrum

D.

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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Related Questions

Correct Answer is ["A","B","C","D"]

Explanation

Findings that require immediate follow-up:

  • Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
  • Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
  • Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

  • Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
  • Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

Correct Answer is A

Explanation

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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