Growth and development of the toddler

Parents and their 35-month-old child have returned to the clinic for a follow-up appointment. Which of the findings may signal a speech delay?

Uses two-word sentences or phrases -A child nearly 3 years of age should speak in three- to four-word sentences.

What statement by the mother of a 20-month-old indicates a need for further teaching about nutrition?

"I give my daughter juice at breakfast and when she is thirsty during the day." -High juice intake can contribute to either obesity or appetite suppression. None is needed, but if juice is given limit the amount to 4 to 6 ounces daily. Water should be the choice for thirst.

The grandmother is the primary caregiver of her 2-year-old granddaughter. She expresses her concern that the child has temper tantrums two or three times a day, often in public places. She explains that she spanked her own children when they did this but now she is worried that spanking is not the best way to handle the situation. Which statement is the most appropriate regarding dealing with the child who has a temper tantrum?

"Remain calm, pick the child up, and move her to a quiet and neutral place until she gains self-control; don't give in to her demands."

Risk Factors for Lead Screening

- Child lives in or cared for in house built before 1950 or before 1978 that has undergone renovation - Has a sibling or playmate followed for elevated lead levels - Lives with a person whose jobs or hobbies involve lead exposure - pottery, car, paint - Live near industrial site

Toddler learning ability

- Curiosity- need to make sure they are safe - Trial and error- 12-18 months - Mimicking behaviors - 2-3 years increased use of symbols and words and pretend play

Best response to temper tantrum

- Ignore them as long as they are safe- don't try to stop it (just like you would a seizure)

The parents of a 3-year-old boy have asked the nurse for advice about a preschool for their child. Which suggestion is most important for the nurse to make?

"The staff should be trained in early childhood development."

Social Factors Demographic Changes in Family

- Increasing rate of divorce and remarriage - Delays and declines in childbearing - Rise in female workforce - Increasing incidence of single parent families - Childhood poverty, unemployment - Homelessness, foster families - Incarceration of parent - Composition of "family" changing - extended family members provide care, same sex parents

The nurse is talking with the parents of a newborn who is being discharged following an uneventful delivery. The parents express their excitement about going home but have concerns about what they need to do to help their 2-year-old adjust to the new baby. Which suggestion would be most appropriate for the nurse to offer these parents?

"You should plan some time for the primary caregiver to focus on the toddler while the secondary caregiver focuses on the infant." -The secondary caregiver can occasionally take over the care of the new baby while the mother or other primary caregiver devotes herself to the toddler. The primary caregiver might also plan special times with the toddler when the new infant is sleeping and the caregiver has no interruptions. This approach helps the toddler feel special.

While observing a 13-month-old and her parents in the playroom of the hospital unit, the nurse notes that the toddler is using her index finger to point towards a toy. How should the nurse respond?

"Your daughter is demonstrating fine motor skills appropriate to her age by pointing with her index finger." -At 12 to 15 months of age the toddler should be feeding herself finger foods and using her index finger to point to objects.

Toddler Growth

- 5-10 lbs per year - 3 inches a year - Continued eruption of teeth - Look potbellied and bow-legged

Infant reflexes

- 6-8 weeks- social smile - 4 months- all reflexes should be gone except Babinski

Promoting Growth and Development of the Toddler

- Age appropriate toys: blocks, walkers - Read to the child everyday - Talk and singing - Understanding developmental norms so parents have realistic expectations

Autonomy vs. Doubt

- Being to develop independence - May feel shame or doubt

Cognitive Domain - Language Development

- Influenced by social interactions and exposures - Receptive language is far more developed than expressive language development; they can understand more than speak - By 2 years of age, should speak about 50 words

Toddler Elimination

- Most toddlers are psychologically and physiologically ready to toilet train between 18 and 30 months (bowel sphincter control, think about balance, should be able to undress, sit up, should have an interest) Night control comes 9 months to 1 yr later - Majority of children achieve daytime bowel and bladder training simultaneously with an average age of 28 months - Nighttime control generally occurs about 1 year after daytime control is achieved

Nutrition in the Toddler

- Nutrition primarily from breastmilk/formula in infancy, now source is food - Weaning from the bottle should occur between 12-15 months - Should use cup, or cup's without valves, use sippy cup (no valves) at 1 yr - Should move to cow's milk around 12 months, whole milk for first 1 yr (at least), then 2 % - Limit milk intake to 16-24 ounces a day - Limit juice to 4-6 oz/day - Water ok• >10% percent of saturated fat -1.2grams/kg protein -100ml/kg fluid (depending on activity and climate)? -iron deficiency most frequently occurs 12-36 mths -500 mg of calcium daily -Daily iron 10mg --Fat intake should not be restricted in -children younger than 2 yrs old: first 2 yrs of life require higher energy needs -Iron deficiency anemia is common so encourage iron fortified cereals -3 full meals/day and 2 snack

Toddler Sleep

- One to 3 year olds usually sleep 10 to 12 hours a night and take 1 to 2 naps - Move to youth bed when crib is unsafe due to possible ability to climb out, usually around age 2 to 3. - Toddlers need rituals and consistency at bedtime as well as security objects - blankets, special toy - If child wakens, quietly reassure child and let them fall asleep in their own bed•• -18 mo - 12.5 hours /day -24 mo-13 hours/ day -3 yr old- 12 hours/ day --Typical toddler should sleep through the night and take one day time nap --Most children discontinue daytime napping around 3 yrs old

Becoming aware of gender differences

-observe the difference btw male and female body parts if they are exposed to them -toddlers may question parents about these differences and may start to explore their own genitals -make observations about gender specific behavior and mimic social gender differences

Average weight for a 2 year old

12 kg

Infant looking in same direction as sound

12-16 weeks

When you should begin brushing childs teeth with tooth paste

2 yrs old -1st dentist visit should be at 1 yr old

Recognize caregiver

4 months

Know that caregivers are different from strangers

6 months

Stranger anxiety

8-10 months

The nurse is providing parental anticipatory guidance to promote healthy emotional development in a 12-month-old boy. Which statement best accomplishes this?

A regular routine and rituals will provide stability and security. -Toddlers benefit most from routines and rituals that help them anticipate events and teach and reinforce expected behaviors

The parents of a 30-month-old girl have brought her into the emergency department because she had a seizure. During the health history, the nurse suspects the child had a breath-holding spell. Which parental report suggests breath-holding?

A tantrum preceded the event. -The fact that there was a precipitating event of frustration and anger points to the likelihood that this is a cyanotic breath-holding spell. Breath-holding spells never occur during sleep, nor do they feature postictal confusion.

The best way for parents to aid a toddler in achieving his developmental task would be to:

Allow him to make simple decisions. -Making decisions is primary practice toward achieving independence

The nurse is assessing a 2-year-old boy during a well child visit. The nurse correctly identifies the child's current stage of Erickson's growth and development as:

Autonomy versus shame and doubt -The Erickson stage of development for the toddler is autonomy versus shame and doubt. During this period of time the child works to establish independence. Trust versus mistrust is the stage of infancy. Initiative versus guilt is the stage for the preschooler. Industry versus inferiority is the stage for school-aged children.

The nurse is assessing a 2 year old boy during a well child visit. The nurse correctly identifies the child's current stage of Erickson's growth and development as:

Autonomy versus shame and doubt.

Erikson

Autonomy vs Shame and Doubt

Motor Development

CNS maturation during toddler years allows for improved control and coordination of both gross and fine motor skills Due to myelination of spinal cord

Growth of the Toddler

Continues to be rapid, decreased velocity from infancy Toddlers generally reach half of their adult height by age 2 3.5-4 in./year, 4 lbs/year

Infant communication

Cry, babble- coo- duplicate words- simple, meaningful words by 1

The mother of a 2-year-old tells you she is constantly scolding him for having wet pants. She says her son was trained at 12 months, but since he started to walk, he wets all the time. Which nursing diagnosis would be most applicable?

Deficient parental knowledge related to inappropriate method for toilet training -It is probable that a child toilet trained at 12 months was not truly trained; his mother was trained to remind him or place him on a toilet frequently during the day. When the child begins to play independently, the training is no longer effective.

Oral Health

Dental Care - brush teeth in am and pm - "smear" of fluoridated toothpaste until age 2, then pea sized amount - First dental visit by 1 year of age Can take child along to your dental appointment if appropriate.

The nurse is providing anticipatory guidance to the parents of an 18 month old girl. Which recommendation will be most helpful to the parents?

Describing proper behavior when she misbehaves

Physical Examination of Toddler R/T Growth and Development

Developmental considerations - stages of autonomy vs shame and doubt striving for independence - negativism and temper tantrums common - beginning of magical thinking - major fears - separation from parents, intrusion of body orifices, loss of control, pain

Leading cause of unintentional injury and death in US children?

Drowning

Emotional Development

Focused on self-egocentrism Power struggles; sleeping, food, want immediate gratification; set limits, routines (without this can have tantrums) Independence versus dependence

Hospitalized Toddler

Give choices when you can Provide comfort objects, use parents Stay on routine

The parents of an overweight 2 year old boy admit that their child is a bit "chubby", but argue that he is a picky eater who will eat only junk food. Which is the best response by the nurse to facilitate a healthier diet?

Give him more healthy choices with less junk food available

The nurse is teaching a mother of a 1 year old girl about weaning her from the bottle and breast. Which recommendation would be part of the nurse's plan?

Give the child an iron-fortified cereal

The nurse is teaching the mother of a 2-year-old boy about age-appropriate toys. Which would be of most interest plus stimulating to the growth and development of this child?

Giving the child bowls, pot, pans, and large spoons -The kitchen items are usually of most interest since they give opportunity to copy observed parental actions. Also, these items can be used not only to role model but also to stack, nest, make noise, and rearrange in many configurations. They are also inexpensive.

Promoting gross/fine motor development in immobilized toddler

Gross- play catch, throw ball Fine- puzzles, blocks, colors, feeding themselves

Tantrums

Guidance for parents: - Provide routine - Direct them to something else - Give them small choices on matters - Provide quiet, calm, hug them - Comfort objects Normal at this age, diminished at 4/5 Redirection, Time out: 1 yr old 1 minute, 2 yr old 2 minutes, ignore the child, keep them near you

The nurse is discussing sensory development with the mother of a 2 year old boy. Which parental comment suggests the child may have a sensory problem?

He doesn't respond if i wave to him

Transductive

Inability to envision situations from perspectives other than one's own

The mother of an 18 month old girl voices concerns about her child's social skills. She reports that the child does not play well with others and seems to ignore other children who are playing at the same time. What response by the nurse is indicated?

It is normal for children to engage in play alongside other children at this age

How can the nurse help the infant develop trust?

Meet immediate needs - Hunger, diaper change

Reasons for temper tantrums

Natural drive toward independence and the inability to communicate what they want - Egocentric thinking - Too much stimulation

Why is infant trust important

Need to feel secure, safe and comfortable in own environment

The nurse is teaching a first-time mother with a 14 month old boy about child safety. Which is the most effective overall safety information to provide guidance for the mother?

Never let him out of your sight

The nurse is caring for a hospitalized 30-month-old who is resistant to care, is angry, and yells "no" all the time. The nurse identifies this toddler's behavior as 1. Problematic, as it interferes with needed nursing care. 2. Normal for this stage of growth and development. 3. Normal because the child is hospitalized and out of his routine.

Normal for this stage of growth and development.

Procedure of giving toddler oral med/IV

Oral- Give them options- do they want their medicine with water or gatorade; do they want the nurse to give them med or their mom IV- which hand?

Toddler play

Parallel play- moving toward cooperative play by end of this stage - Know that certain action have consequences but don't understand why

Three Fundamental Domains

Physical Cognitive Psychological/Social

The nurse is observing a play group of children of all ages. The toddlers in the group would most likely be doing which activity?

Playing with the plastic vacuum cleaner pushing it around the room -Playtime for the toddler involves imitation of the people around them such as adults, siblings, and other children. Push-pull toys allow them to use their developing gross motor skills.

Toddler language

Progress from barely being able to speak- to understand words- to conducting simple conversations

Toddler toilet training

Ready when they start showing interest- start to know they are wet, watch parents go to the bathroom and start sitting on the toilet - 2-3 years of age - Any younger than 18 months don't really have the ability to hold and release urine

Parents of a toddler describe how they handled their child's temper tantrum in a shopping mall. What action of the parents indicates need for additional teaching?

Reasoned with the child to stop the behavior -The child having a tantrum is out of control, making reasoning impossible

The mother of a 15-month-old is concerned about a speech delay. She describes her toddler as being able to understand what she says, sometimes following commands, but using only one or two words with any consistency. What is the nurse's best response to this information? 1. The toddler should have a developmental evaluation as soon as possible. 2. If the mother would read to the child, then speech would develop faster. 3. Receptive language normally develops earlier than expressive language. 4. The mother should ask her child's physician for a speech therapy evaluation.

Receptive language normally develops earlier than expressive language.

A 2-year-old holds his breath until he passes out when he wants something his mother does not want him to have. You would base your evaluation of whether these temper tantrums are a form of seizure on the basis that:

Seizures are not provoked; temper tantrums are.

Piaget

Sensory Motor Stage - 0-2 yrs Preoperational - 2-7 yrs - learning through symbolism, imitation (refined in toddler years)

The nurse is providing education to a teen mother about her 20-month-old daughter's growth. The teen says her daughter seems to have such a big head. What information should the nurse include in the response?

Share that the heads of children at this age are large in proportion to the rest of their body. -Head circumference increases about 1 inch between 1 and 2 years of age, then increases an average of a half-inch per year until age 5. The anterior fontanel should be closed by the time the child is 18 months old. Head size becomes more proportional to the rest of the body near the age of 3 years.

The parents of a 2 year old girl are concerned with her behavior. For which behavior would the nurse share their concern?

She frequently babbles to herself when playing

Communicating with infant

Soft, quiet, high pitched voice; smiling, bright, cheery - Communicate with parent first- infant sees you talking to parent so they feel safer with you

The nurse is assessing a 3 year old child. The nurse notes the child is able to understand that objects hidden from sight still exist. The nurse correctly documents the child is displaying:

Tertiary circular reactions

The nurse is observing a 3 year old boy in a daycare center. Which behavior might suggest an emotional problem?

The child has persistent separation anxiety.

The nurse is observing a 36 month old boy during a well visit. Which motor skill has he most recently acquired?

The child is able to undress himself

The nurse is assessing the language development of a 3 year old girl. Which finding would suggest a problem?

The child speaks in 2-3 word sentences

The parents of a 3 year old boy have asked the nurse for advice about a preschool for their child. Which suggestions is most important for the nurse to make?

The staff should be trained in early childhood development

Pain Assessment of Toddler

Toddlers (and preschoolers) may not understand quantitative ratings - Fear of being asked questions by strangers - Will often give you an answer even if they don't understand the question - Will often use extremes of scales - What pain scales might you use? Can be shown in a difference in activity level (no playing etc)

Play is the work of children

Toddlers are on-lookers with curious watching of other children playing Parallel play - becomes the predominant style of play with toddlers engaged in similar play activity with minimal interaction. - language development, learning occurs

Toddler Nutrition

Toddlers don't require as many calories per size than they did in infancy - Physiologic anorexia: dont want to take in food - Food jags: only eating one thing, include in at least 1 family meal, reinforce offering new things Offer 3 meals and 2 snacks daily - ¼ of adult portion sizes - Anticipatory guidance for parents - Family meals - Don't battle! - Continue to offer varieties

Proximodistal growth pattern

Torso control before hand/finger control - Rolling over before they hold a rattle

The best way for a parent to handle a temper tantrum by a toddler is to calmly express disapproval and then ignore it.

True

The nurse is discussing the activities of a 20 month old child with his mother. The mother reports the children of her friends seem to have ore advanced speech abilities than her child. After assessing the child, which of the following findings is cause for follow-up?

Understands approximately 75 to 100 words.

Infant Growth

Weight- doubles by 6 months; triples in one year

Seperation anxiety

peaks at 14-18 months

Echolalia

repetition of words and phrases without understanding

Telegraphic speech

speech that contains only the essential words to get the point across

Emotianl lability

very happy and pleasant one moment then overreacting with a temper tantrum in the next moment

Gender Development

- Two year old can distinguish gender and will identify themselves as boy or girl - Age three beginning to show sex-typed preferences

Cepholacaudal growth pattern

Head to toe - Have stronger neck muscle and hold head up before they learn to walk

Developmental Screening Assessment tools used in Toddler Care

- Ages and Stages Questionnaire (ASQ) parent completed child monitoring system for children 4 to 48 months - Denver II screens personal, social, fine motoradaptive, language and gross motor domains in children birth to 6 years - M- CHAT Checklist for Autism in Toddlers (no eye contact, less social ability)

How can the nurse promote the toddler development of autonomy?

- Allow them to feed themselves, dress themselves, brush hair/teeth - Give them choices

Toddler Safety

- Apply recommendations given for infant plus; - Emphasize street safety- begin teaching basic rules of pedestrian and traffic safety - Avoid strangers - teach child methods to avoid encounters with strangers that can be harmful (teaching what is inappropriate behavior) - Rear facing in car seat as long as possible (manufacturer recs), then forward facing - Helmets with any type of bicycle (as passenger) - Enroll in swimming lessons and supervise around water - Supervise around playground equipment

Toddler and Health Activity

- Avoid television - AAP does not recommend TV for children 2 years or younger. - Physical activity - choose family activities that encourage physical activity (walking, tag, short hikes, etc.). Take stairs over escalators. - Toys should stimulate achievement of skills and appropriate for age

Additional Screening

- Body mass index beginning age 24 months - Vision screen ages 3 (cover/uncover test) - Hearing screen- gross evaluation - Lead screening based on risk factors and medicaid patients between ages one and two (lead level) Lead toxicity - learning disabilities, cog impairment - Anemia screening

Family Functioning

- Increasing rate of divorce and remarriage - Delays and declines in childbearing - Rise in female workforce - Increasing incidence of single parent families - Childhood poverty, unemployment - Homelessness, foster families - Incarceration of parent - Composition of "family" changing - extended family members provide care, same sex parents

Potty Training

- Should not be started when family is stressed (new baby, moving, holidays, divorce) - Suggestions for parents - praise all efforts, expect accidents to happen, don't punish, if child is resistant, try again in a few weeks, follow usual pattern of elimination, limit time on potty to 5 to 10 minutes.

Assessment of Risk Prevention for Toddler Related to Growth and Development

- Smoke, radon and carbon monoxide detector - Hot water heater setting (120 or less), water safety - Use of toddler car seat - properly installed - Childproofing home (and childcare center/provider) appropriate to age; poison, meds - use locks - Pet safety, gun safety - Use of sunscreen SPF 30 or higher

Toddler Parenting and Discipline

- Use limit setting and time-out for inappropriate behavior (one minute for each year of age) - Praise good behavior - Emphasize consistency, especially between parents - Spend time with child daily, especially reading - Be a role model - Assign chores appropriate for age - putting toys away - Begin socialization with other children - Limit television, correlation with aggressive play, watch with child, appropriate content (may affect parents viewing habits); no screen time under 2

Approaches to Physical Exam

- Use of distraction helpful - Allow child to touch and hold equipment before examination - Demonstrate examination on doll, toy or parent before conducting - Give child choices when possible - Conduct as much of examination on parent's lap as possible - Conduct using a noninvasive to invasive sequence

Emotional and social development of the Toddler

-Individualization: forming a sense of self and learning to control ones environment leads to emotional lability -Egocentrism: focus on self (toddlers don't reapply play together)

Toilet teaching with toddler

-Myelinization of spinal cord complete by 2 yrs so toddler is able to exercise control over sphincters

Measuring Growth

Height, weight, head circumference from age 1 to 3 obtained at each well child visit and plotted on appropriate growth chart to age 3 if HC has been appropriate until age 2, dont need further measurements Recumbent length is plotted on birth to age 3 chart, upright height is plotted on ages 2 through 18 chart

The nurse has completed an examination of a 32-month-old girl with normal gross and fine motor skills. Which observation would suggest the child is experiencing a problem with language development?

Her vocabulary is between 10 and 15 words. -A 3-year-old child typically has a vocabulary of approximately 900 words, asks many questions, uses complete sentences consisting of 3 to 4 words, and talks incessantly.

The nurse is observing a 3-year-old boy in a day care center. Which behavior might suggest an emotional problem?

Has persistent separation anxiety -Separation anxiety should have disappeared or be subsiding by 3 years of age. The fact that it is persistent suggests there might an emotional problem.