A nurse is assessing an 18-month-old toddler at a wellness visit in the health care provider's office. During the assessment, the nurse asks the parent about developmental milestones. The parent states that the toddler has not said their first word yet. Which of the following priority actions by the nurse is accurate?
Complete a screening test for autism spectrum disorder (ASD).
Ask the parent if the toddler has a history of hospitalizations or surgeries.
Ask the parent about recent immunizations.
Educate the parent that toddlers do not typically say their first word until 18-20 months of age.
The Correct Answer is A
A. Complete a screening test for autism spectrum disorder (ASD): By 12 months, most toddlers use simple words such as “mama” or “dada” with meaning. Absence of first words by 18 months is a red flag for possible developmental delay, including ASD, and warrants immediate standardized screening to allow early identification and intervention.
B. Ask the parent if the toddler has a history of hospitalizations or surgeries: Past medical history is relevant, but it does not address the immediate developmental concern of delayed expressive language. Developmental screening takes priority when milestone delays are identified.
C. Ask the parent about recent immunizations: Immunization history is important for preventive care but is unrelated to delayed speech development and does not guide immediate assessment or intervention for language delay.
D. Educate the parent that toddlers do not typically say their first word until 18–20 months of age: Most toddlers speak their first meaningful word well before 18 months. Providing reassurance without further evaluation delays necessary screening and early referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The final booster dose is administered at 12 to 15 months of age: The Hib vaccine series is completed with a booster in the second year of life, which ensures long-term immunity against invasive Hib infections.
B. The vaccine is administered intramuscularly: Hib vaccine is given via IM injection, typically in the anterolateral thigh for infants or the deltoid for older children, which is important for proper absorption and immune response.
C. The first dose of this vaccine can be administered to a newborn immediately after birth: The Hib vaccine is not given at birth; the series begins at 2 months of age according to the recommended immunization schedule.
D. The vaccine reduces the risks for meningitis and epiglottitis: Hib vaccination protects against serious infections caused by Haemophilus influenzae type b, including meningitis, epiglottitis, and pneumonia, reducing morbidity and mortality.
E. An allergy to eggs is a contraindication to this vaccine: Egg allergy is not a contraindication for Hib vaccine; it is safe for children with this allergy.
Correct Answer is B
Explanation
A. Spine: Rhabdomyosarcoma rarely originates in the spine. While metastasis can occur to various sites, the spine is not a common primary location for this tumor in pediatric clients.
B. Head: Rhabdomyosarcoma most frequently arises in the head and neck region, including the orbit, nasopharynx, and paranasal sinuses. Tumors in this area often present with swelling, proptosis, or nasal obstruction, reflecting the typical manifestation sites in children.
C. Ribs: The ribs are an uncommon site for primary rhabdomyosarcoma. While thoracic involvement may occur secondary to metastasis, initial tumors in this location are rare.
D. Upper leg: Extremities can be affected by rhabdomyosarcoma, but the head and neck region is the most prevalent site. Tumors in the limbs are less common, though they may present with swelling or functional impairment if they occur there.
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