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Stranger anxiety typically starts around 6 to 8 months, not 4 months. Additionally, while recognizing developmental behavior is important, the statement doesn’t describe a communication technique.

Preschoolers (ages 3–5) are in the preoperational stage and rely on imagination more than logic. Detailed explanations can increase anxiety and confusion. Instead, simple, concrete terms and play-based explanations such as using a doll are more effective.

Adolescents need autonomy, respect, and honesty. A rigid, one-size-fits-all approach can increase resistance. Therapeutic communication with teens should be flexible, involve them in decision-making, and respect their growing independence.

Gently touching the child’s hair while looking directly into his eyes can be perceived as intrusive or threatening to a toddler, especially before trust is established. Direct eye contact and unsolicited touch often trigger anxiety or defensive behavior in young children.

While smiling is helpful, placing a stethoscope on the chest too soon can alarm a child. The nurse should gradually approach and allow the child to explore or observe instruments first.

A 2-year-old's language skills are limited, and many may not yet be capable of detailed verbal responses. This approach may cause frustration or confusion rather than cooperation.

While obtaining the history is important, this is not the priority when abnormal vital signs suggest possible neurological compromise. Assessment and stabilization take precedence over gathering subjective data.

Rescue breaths are indicated for apnea or severe respiratory distress, neither of which is currently present (RR: 12 rpm is within normal range for age). Inappropriately providing rescue breaths could cause harm.

Although carefully examining the child’s head for signs of fracture is relevant in head trauma, it is not the immediate priority when life-threatening signs such as bradycardia and hypotension are present. These findings require urgent escalation, not just local examination.

Behavioral cues such as grimacing and guarding are helpful, especially for non-verbal or very young children, but observation alone is subjective and may underestimate or misinterpret pain.

While asking directly can be useful, open-ended verbal questions may be too abstract for a 5-year-old to answer accurately. Structured tools are more effective for this age.

Parental input can supplement pain assessment, especially in very young or nonverbal children, but in a verbal 5-year-old, the child’s self-report is preferred when possible. Relying solely on the parent may lead to inaccurate estimation.

Asking the child to follow the nurse’s fingers in all six quadrants assesses extraocular muscle movement (EOM), not accommodation. It's used to check for strabismus, cranial nerve function, and eye alignment, not lens focusing ability.

Having the child cover one eye and read from a vision chart tests visual acuity, not accommodation. While important in a full eye exam, this doesn’t assess how the eyes adjust focus from far to near.

Using an ophthalmoscope to assess for the red reflex screens for ocular opacity or abnormalities in the retina, such as cataracts or retinoblastoma, not accommodation.

While drooling and chewing begin as early signs of teething, by 7 months, the first teeth have usually started to erupt. The complete absence of teeth could still be within normal limits, but is less typical than having two lower incisors.

Upper central incisors typically erupt after the lower ones, usually around 8–12 months. At 7 months, it would be early for these to be the first and only teeth present.

Presence of both upper and lower incisors generally occurs closer to 9–12 months. While some infants may develop teeth earlier, four incisors at 7 months is ahead of the typical developmental timeline.

While parents can assist in calming the child, the nurse must maintain control during an oral assessment to ensure safety and proper technique. Relying on the parent may not offer adequate control or bite prevention.

A 2-year-old may not consistently follow verbal instructions, especially during unfamiliar or uncomfortable procedures. Cooperation at this age is unpredictable, and this method doesn’t provide physical safety against sudden closure of the jaw.

Inserting a tongue blade without stabilizing the mouth may provoke biting and result in injury to the nurse or discomfort to the child. It should be done only after securing the cheeks or using proper restraint techniques.

Asking the child to whisper the words while assessing the tympanic membrane is incorrect because the whisper test assesses the child’s ability to hear, not speak. Also, tympanic membrane inspection and hearing evaluation are separate components of an ear exam.

Asking the child to whisper into the nurse’s ear evaluates the child’s speaking volume, not their hearing ability, and does not provide information about auditory perception.

Asking the child whether or not he hears his friends when they whisper to him is subjective and may not accurately reflect the child's hearing ability. A proper assessment requires objective observation, not just self-reporting.

Talking about a teddy bear may engage the child but provides limited and less comprehensive developmental information compared to active play observation.

Screening tools are helpful but often rely on structured questions or parental input; they don’t provide as much real-time, holistic information as play observation.

Asking the sibling might offer anecdotal insight but is not a reliable or objective method for developmental assessment.

Umbilical hernias are common in infants and toddlers but usually resolve by age 3–5; persistence at age 7 is abnormal and would require evaluation.

The liver may be palpable 1–2 cm below the right costal margin in infants and toddlers, but in older children, it should generally not be felt below the costal margin unless enlarged.

The spleen is not normally palpable in healthy children; palpation below the left costal margin suggests splenomegaly and requires further investigation.

While a soft scrotal sac without masses may seem benign, the absence of palpable testes could indicate cryptorchidism, which should be reported for further evaluation.

Wide-spread labia majora in a preschool girl may suggest hormonal influence (e.g., from androgen exposure) or an anatomical variation requiring assessment.

Vaginal discharge with a fishy odor is abnormal and often associated with infection such as bacterial vaginosis or a foreign body, both of which require prompt evaluation.

The Moro reflex (startle reflex) usually disappears by 4–6 months; persistence beyond this age may indicate neurological issues.

The trunk incurvation (Galant) reflex typically disappears by 4–6 months of age.

The palmar grasp reflex usually fades by 5–6 months as voluntary grasping replaces the reflexive action.