A nurse is caring for a toddler in the pediatrician's office.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate antibiotic therapy for the child:
Bacterial meningitis is a medical emergency. Early administration of antibiotics is critical to reduce morbidity and mortality.
B. Minimize the child's environmental stimuli:
Reducing stimuli helps decrease ICP and is important, but it is not the first priority — treating the infection comes first.
C. Place the child in a side-lying position:
While positioning can help manage seizures or airway concerns, it does not treat the underlying infection.
D. Administer pain medication to the child:
Pain management is important but secondary to initiating life-saving treatment (antibiotics).
Correct Answer is D
Explanation
A. Dry mouth
This is not a common or concerning side effect of cefazolin.
B. Constipation
Not a typical or serious adverse effect of cefazolin.
C. Back pain
While back pain can be a side effect of some medications, it is not typically associated with cefazolin and not a first-line concern unless accompanied by other symptoms.
D. Urticaria
Urticaria (hives) can indicate an allergic reaction to cefazolin, which is a cephalosporin antibiotic. This requires prompt reporting and possible discontinuation of the drug.
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