A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?
Remove the toddler's outer clothing.
Discourage the toddler from sitting in the parent's lap.
Allow the toddler to inspect the stethoscope.
Perform traumatic procedures first.
The Correct Answer is C
A. Removing outer clothing can be uncomfortable or distressing for toddlers, so it is often better to do this gradually, allowing the child to feel more at ease.
B. Allowing the toddler to sit in the parent's lap can provide comfort and security during the examination.
C. Allowing the toddler to inspect the stethoscope is an effective way to reduce anxiety and establish trust with the child.
D. Traumatic procedures, such as immunizations or blood draws, should be done last to avoid causing unnecessary distress during the examination.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
Correct Answer is D
Explanation
A. Growth and changes in height and weight accelerate during adolescence, particularly in the early years, as part of the growth spurt.
B. While it is important to involve parents, adolescent clients should be encouraged to participate in decision-making about their health, as they are developing autonomy. Health decisions should include both the adolescent and the parents when possible.
C. Adolescents are often highly interested in discussing health promotion, particularly topics that are relevant to their peer group, such as body image, sexual health, and mental health.
D. The timing of puberty can significantly impact an adolescent’s self-esteem. Early or late onset of puberty may lead to feelings of self-consciousness or social challenges. Understanding this developmental change is essential in supporting the adolescent’s emotional and psychological well-being.
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