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 B
Explanation
A. "Seal non-washable items in a plastic bag for 2 days."
Items should be sealed for 14 days, not 2 days, to ensure lice and nits die due to lack of air.
B. "Soak hairbrushes in boiling water for 10 minutes."
This is an effective way to kill lice and nits on combs and brushes.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
Permethrin should be applied once, and reapplication is recommended in 7 to 10 days if needed—not daily.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
Items should be dried on a high heat setting to kill lice and nits.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}
Explanation
When planning care for the infant, the nurse should prepare the infant for a rectal biopsy and frequently measure abdominal circumference.
Rationale for correct answers:
Prepare the infant for a rectal biopsy: Confirms diagnosis of Hirschsprung disease, which is suspected based on symptoms and enema findings.
Frequently measure abdominal circumference: Monitors abdominal distension, a key sign in bowel obstruction or worsening condition.
Rationale for incorrect answers:
Explain the purpose of the pyloromyotomy: This procedure is for pyloric stenosis, not Hirschsprung disease.
Transport the client for a radiologist guided gas enema: Contrast enema already performed.
Administer oral laxatives: Contraindicated in suspected bowel obstruction like Hirschsprung disease.
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