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A 15-month-old child is brought to the clinic for a routine checkup. The nurse notes that the child is not walking independently yet. What should the nurse do next?
- A. Refer the child for a developmental assessment
- B. Encourage the parents to start physical therapy
- C. Reassure the parents that some children walk later than others
- D. Discuss the importance of early intervention services
Correct Answer: C
Rationale: The correct answer is to reassure the parents that some children walk later than others. It is essential to understand that children reach developmental milestones at different ages. Walking independently can occur later in some children, and it is normal. Referring the child for a developmental assessment (Choice A) may cause unnecessary concern at this stage. Encouraging physical therapy (Choice B) or discussing early intervention services (Choice D) may not be warranted unless there are specific concerns identified during the checkup.
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What is the best response for a two-year-old boy who begins to cry when the mother starts to leave?
- A. Let's wave bye-bye to mommy.
- B. Two-year-olds usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: The best response for a two-year-old boy who begins to cry when the mother starts to leave is to wave bye-bye to mommy. This action helps the child understand that the separation is temporary and gives him a sense of closure. Choice A is the correct answer. Choice B is incorrect as it generalizes the behavior of two-year-olds. Choice C may invalidate the child's feelings by telling him to 'be a big boy' instead of acknowledging his emotions and providing comfort.
A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement?
- A. Obtain a specimen for blood cultures.
- B. Assess the CBC.
- C. Monitor the oral temperature every hour.
- D. Administer acetaminophen as prescribed.
Correct Answer: A
Rationale: Obtaining a specimen for blood cultures is crucial in this situation as it helps identify the source of infection, if present, and guide appropriate treatment. This is important in a child with leukemia receiving chemotherapy to prevent potential complications and ensure timely intervention. Assessing the CBC may provide overall information on the child's condition but may not specifically identify a potential infection. Monitoring the oral temperature is important but obtaining blood cultures takes precedence in this scenario. Administering acetaminophen can help reduce fever but does not address the need to identify a possible infection source.
While teaching a parenting class to new parents, the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors?
- A. Children need help in developing social skills.
- B. This age group fears loss of self-control.
- C. They provide the child with a sense of security.
- D. Children must learn to deal with authority.
Correct Answer: C
Rationale: Implementing discipline and limit setting for infants and toddlers is primarily important as it provides them with a sense of security. This sense of security is crucial for their emotional and psychological development, helping them feel safe and supported as they explore the world around them. Choice A is incorrect because while developing social skills is important, the primary reason for discipline and limit setting in this context is to provide security. Choice B is incorrect as it does not address the main reason for implementing discipline and limit setting. Choice D is incorrect as the primary focus is not about dealing with authority at this early stage of development.
The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?
- A. Laughs readily, turns from back to side.
- B. Has strong Moro and tonic neck reflexes.
- C. Keeps fists clenched, opens hands when grasping an object.
- D. Can lift head, but not chest when lying on abdomen.
Correct Answer: A
Rationale: In infants, laughing readily and turning from back to side are indicative of normal development. These behaviors indicate that the thyroid therapy is effective, as they suggest the baby is achieving age-appropriate milestones. A 5-month-old infant should be able to laugh readily and turn from back to side, showing progress in motor and social development. Choices B, C, and D describe behaviors that are not specific to the expected developmental milestones of a 5-month-old. Strong Moro and tonic neck reflexes, clenched fists, and limited ability to lift the chest when lying on the abdomen are not necessarily indicative of the effectiveness of thyroid therapy for hypothyroidism.
The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?
- A. Laughs readily, turns from back to side.
- B. Has strong Moro and tonic neck reflexes.
- C. Keeps fists clenched, opens hands when grasping an object.
- D. Can lift head but not chest when lying on abdomen.
Correct Answer: A
Rationale: In infants, laughing readily and turning from back to side are developmental milestones that indicate effective thyroid therapy and normal development. These actions demonstrate improved muscle tone, coordination, and overall growth, which are key indicators of successful treatment for hypothyroidism in infants. Choices B, C, and D describe behaviors that are not specific indicators of thyroid therapy effectiveness in treating hypothyroidism in infants.