The practical nurse (PN) is observing a two-year-old child at play.
Which should the PN consider normal behavior for a toddler?
Uses blunt scissors to do cut-outs.
Rides a tricycle around the play area.
Looks at a picture book for 15 minutes.
Takes toys away from another child.
The Correct Answer is D
Choice A rationale
Using blunt scissors to do cut-outs typically requires fine motor skills and hand-eye coordination that are characteristic of older preschool-aged children, generally around 3 to 4 years old. A two-year-old is still developing these complex manipulative skills, making this behavior not typical for their developmental stage.
Choice B rationale
Riding a tricycle generally emerges as a developmental milestone for children between 3 to 4 years of age. This activity demands advanced gross motor coordination, balance, and bilateral pedaling skills that are usually beyond the capabilities of an average two-year-old, who is still mastering walking and running.
Choice C rationale
Sustained attention to a picture book for 15 minutes is a cognitive ability that develops with age, typically seen in older preschool or school-aged children. A two-year-old's attention span is much shorter, usually limited to a few minutes, reflecting their ongoing neurological maturation and cognitive development.
Choice D rationale
Taking toys away from another child is a common and normal behavior observed in toddlers. This is characteristic of their egocentric stage of development, where they struggle with sharing and understanding others' perspectives, often leading to possessive actions as they explore their environment and assert their will.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering ibuprofen may alleviate pain temporarily, but it does not address the underlying cause of increased pain and pressure, which could indicate a developing complication such as a perineal hematoma. Providing only symptomatic relief delays investigation and potential intervention for a serious issue.
Choice B rationale
Increased pain and pressure in the vaginal area following a perineal laceration, especially 6 hours postpartum, are classic signs of a developing perineal hematoma. This condition requires prompt medical evaluation by the healthcare provider to assess the extent of bleeding, potential for shock, and determine the need for surgical intervention.
Choice C rationale
Applying an icepack to the perineum is a common comfort measure for swelling and pain associated with lacerations. While it may provide some relief, it will not resolve a developing hematoma or significant internal bleeding that is causing increased pain and pressure. It is an insufficient intervention for the potential severity of the client's symptoms.
Choice D rationale
Providing routine perineal care, such as gentle cleansing and hygiene, is important for comfort and infection prevention. However, it does not address the acute and increasing pain and pressure that suggests a complication beyond typical postpartum discomfort. This intervention would delay necessary medical assessment for a potential hematoma.
Correct Answer is A
Explanation
Choice A rationale
Rho immune globulin (RhoGAM) is administered to Rh-negative mothers who have given birth to an Rh-positive baby. This injection prevents the mother's immune system from developing antibodies against Rh-positive red blood cells, which could otherwise harm future Rh-positive fetuses in subsequent pregnancies through hemolytic disease of the newborn.
Choice B rationale
If the mother is Rh positive and the baby is Rh negative, there is no risk of Rh incompatibility. The Rh-positive mother's immune system will not produce antibodies against the Rh-negative fetal red blood cells, as she already possesses the Rh antigen. Therefore, Rho immune globulin is not indicated in this scenario, as there is no sensitization risk.
Choice C rationale
When both the mother and the baby are Rh negative, there is no Rh incompatibility. Since neither the mother nor the baby has the Rh antigen, the mother's immune system will not be stimulated to produce anti-Rh antibodies. Consequently, Rho immune globulin administration is unnecessary in this situation, as no immune response will be triggered.
Choice D rationale
The Rh status of the father is relevant in determining the potential for Rh incompatibility, but it does not directly dictate the need for Rho immune globulin. The critical factor is the Rh status of the mother and the baby. If the mother is Rh positive, regardless of the father's Rh status, she will not produce Rh antibodies, and RhoGAM is not indicated.
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