A nurse is assessing an 18-month-old toddler during a well-child visit. Which of the following findings should the nurse identify as a potential developmental delay?
Engages in parallel play
Builds a tower of 3 blocks
Walks with assistance
Speaks at least 10 words
The Correct Answer is C
A. This is typical behavior for an 18-month-old toddler. They often play alongside others without interacting directly.
B. This is a normal developmental milestone for an 18-month-old child.
C. An 18-month-old child should be able to walk independently. Difficulty walking with assistance could indicate a potential developmental delay.
D. While vocabulary varies, most 18-month-olds can say a few words. This is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vomiting after administering digoxin could be a sign of digoxin toxicity or intolerance. Before giving another dose, it is crucial to assess the infant’s condition, check for signs of digoxin toxicity, and consult with the healthcare provider. Administering the next dose without addressing the underlying issue could worsen the situation.
B. Mixing digoxin with a large volume of formula is not recommended. Digoxin should be administered in precise doses, and diluting it in such a large volume could lead to inaccuracies in dosing. Furthermore, mixing medication with formula does not address the issue of vomiting or potential toxicity.
C. While giving an antiemetic might seem like a solution to vomiting, it does not address the root cause of the vomiting, which could be related to digoxin toxicity or another issue. The first step should be to
assess the situation and determine if the vomiting is related to digoxin levels, and then consult with the healthcare provider. They may recommend appropriate interventions based on the infant’s condition.
D. Increasing fluid intake might be beneficial to prevent dehydration from vomiting, but it does not address the potential underlying cause of the vomiting, which could be related to digoxin toxicity. It is important to focus on the underlying cause and consult with the healthcare provider to determine the appropriate action. Managing fluid intake alone does not resolve the issue with digoxin or its side effects.
Correct Answer is B
Explanation
A. Soy milk is not recommended for infants under one year of age. It does not provide the necessary nutrients for their growth and development.
B. Commercially prepared infant formula is specifically designed to meet the nutritional needs of infants. It is the best alternative to breast milk for infants having difficulty eating.
C. While warming milk might be comforting, it does not address the underlying issue of goat milk being an inappropriate nutritional source for a 10-month-old infant.
D. Breast milk is the best source of nutrition for infants. However, if breastfeeding is not possible, formula is the next best option.
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