The nurse is caring for a 9-month-old child.
The nurse assesses the baby and finds all of the following data.
Which finding is of MOST concern and leads the nurse to consider a possible referral to Early intervention for developmental delay?
Inability to pick up crackers with thumb and forefinger.
Playing with a toy for only a few minutes.
Ability to crawl on all fours supported on hands and knees.
Inability to pull self to a standing position.
The Correct Answer is A
Choice A rationale
By 9 months, most babies have developed the fine motor skills necessary to pick up small objects, like crackers, with their thumb and forefinger. This is known as the pincer grasp. If a 9- month-old child is unable to do this, it could be a sign of a developmental delay.
Choice B rationale
It’s normal for babies at this age to have a short attention span. They often play with a toy for only a few minutes before moving on to something else. Therefore, this behavior is not typically a cause for concern.
Choice C rationale
The ability to crawl on all fours supported on hands and knees is a typical developmental milestone for a 9-month-old child. Therefore, this behavior is expected and does not indicate a developmental delay.
Choice D rationale
While some 9-month-old babies may be able to pull themselves to a standing position, not all babies develop this skill at the same time. Therefore, the inability to do this is not necessarily a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Seizures, confusion, and weakness are symptoms that a nurse should anticipate when assessing a child suffering from hypotonic hyponatremia with a sodium level below 114
mEq/L2. Severe hyponatremia can lead to cerebral edema, resulting in neurologic symptoms such as seizures and confusion.
Choice B rationale
Mild tingling and numbness in fingers are not typically associated with hyponatremia. These symptoms are more commonly associated with conditions affecting the nervous system or with electrolyte imbalances such as hypocalcemia.
Choice C rationale
Frequent urination and fluid retention are not typical symptoms of hyponatremia. They are more commonly associated with conditions such as kidney disease or heart failure.
Choice D rationale
A temperature of 96°F orally and drowsiness are not specific symptoms of hyponatremia. While drowsiness can occur with severe hyponatremia due to cerebral edema, a low body temperature is not typically associated with this condition.
Correct Answer is A
Explanation
Choice A rationale
Supervising the child in outdoor, fenced play areas is a key safety measure for toddlers. At this age, children are exploring their environment and may not be aware of potential dangers.
Fenced play areas provide a safe space for the child to play while still being under the watchful eye of the parents. This demonstrates an understanding of the child’s safety needs.
Choice B rationale
Allowing a toddler to cross the street with a 6-year-old sibling is not a safe practice. Children at this age do not have the cognitive ability to understand the dangers of traffic and cannot make safe decisions about when to cross the street. Therefore, this action does not demonstrate an understanding of the child’s safety needs.
Choice C rationale
Using an automobile booster seat with a lap belt is not appropriate for an 18-month-old toddler. According to safety guidelines, children under the age of 2 should be in a rear-facing car seat, and children between the ages of 2 and 4 should be in a forward-facing car seat with a harness. Booster seats are typically used for older children who have outgrown their forward- facing car seats. Therefore, this action does not demonstrate an understanding of the child’s safety needs.
Choice D rationale
Teaching a toddler about swimming and water safety is important, but it is not enough to ensure the child’s safety. Toddlers should always be supervised around water, even if they have had swimming lessons. Drowning is a leading cause of death in toddlers, and it can happen quickly and silently. Therefore, while teaching water safety is a good step, it needs to be combined with other safety measures.
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