A nurse is caring for a toddler in the pediatrician's office.

Exhibits
Click to highlight the findings that indicate this client may be experiencing a developmental delay. To deselect a finding, click on the finding again.

Nurses Notes

Today

The toddler returns to the office for a routine 2-year-old check-up. The parents report no issues at home, but state that the teachers at the child's daycare center are concerned that the child is behind.

Fine motor: rotates utensils to bring them to their mouth

Gross motor: walks independently, scoots on bottom up and down stairs

Language: uses one-word sentences, can say 5 words

Play: participates in parallel play with their siblings, does not notice when others are upset

Height 86.4 cm (34)

Weight 11.3 kg (24.9 lb)

rotates utensils to bring them to their mouth

scoots on bottom up and down stairs

does not notice when others are upset

uses one-word sentences, can say 5 words

Answer and Explanation

The Correct Answer is ["C","D"]

Findings that indicate a developmental delay:

Language: uses one word sentences, can say 5 words- At age 2, toddlers are expected to use at least two-word phrases and have a vocabulary of about 50 words. This finding suggests a delay in expressive language development.

Play: does not notice when others are upset- At this age, toddlers begin to show empathy or awareness of others' emotions. Not noticing when others are upset could indicate a delay in social-emotional development.

Rationale for incorrect findings:

Fine motor: rotates utensils to bring them to their mouth- This is an age-appropriate fine motor skill.

Gross motor: scoots on bottom up and down stairs- Although some toddlers may walk up stairs by 2 years, scooting is still within developmental range.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Potential Intervention	Expected	Unexpected	Rationale
Have child tilt head back		✅	Tilting the head back increases the risk of blood being swallowed, which can cause nausea or aspiration.
Insert cotton into nostril		✅	Cotton can be ineffective and may dislodge, worsening bleeding. Use gauze or a nasal tampon if needed.
Apply ice to bridge of nose	✅		Cold vasoconstricts blood vessels, helping reduce nasal bleeding.
Apply pressure to tip of nose for at least 10 min	✅		First-line measure for anterior epistaxis. Correct site is the soft part (lower third) of the nose.
Prepare to administer factor VIII	✅		The child has a Factor VIII deficiency (35%), which is diagnostic of Hemophilia A. Factor VIII replacement is the treatment.
Prepare to administer topical antifibrinolytic agent	✅		These agents help stabilize clots and are used for mucosal bleeds in hemophilia.
Prepare to administer packed red blood cells		✅	Not indicated unless there is severe blood loss with signs of anemia or hemodynamic instability, which is not present here.

A. Green zone reading on peak expiratory flow meter B. Rhinitis C. Axillary temperature of 37.2°C (99°F) D. Hacking nonproductive cough

Correct Answer is D

Explanation

A. Green zone reading on peak expiratory flow meter

Green zone indicates 80–100% of personal best peak flow-this is not a sign of exacerbation.

B. Rhinitis

Rhinitis can be a trigger but is not a sign of an active asthma exacerbation.

C. Axillary temperature of 37.2°C (99°F)

This is a normal temperature for a child and not indicative of an asthma issue.

D. Hacking nonproductive cough

A persistent, dry, nonproductive (hacking) cough—especially at night—is a classic early sign of asthma exacerbation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child in the emergency department (ED). Exhibits For each potential intervention, click to specify if the potential intervention is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

A nurse is preparing a teaching plan for the parent of a school-age child who has asthma. Which of the following manifestations should the nurse include as an indication of an exacerbation of asthma?

Correct Answer is D

Explanation

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