CH.24 Alterations in Growth and Development of the Hospitalized Toddler: 1 to 3 Years

The maximum time-out duration is how many minutes for each year of age?

- 1 minute Explanation: The maximum time-out duration should be 1 minute for each year of age, but it may be necessary to start with much shorter time-outs.

Explain the major developmental task of the toddler according to Erikson

- Autonomy (independence) while overcoming doubt and shame - The toddler seeks independence, wavers between dependence and freedom, and GAINS self-awareness.

The nurse is assessing 2-year-old twins. The parent states, "My twins will not play together, only alongside each other." Which action will the nurse take first?

- Explain that this is normal behavior for toddlers. Explanation: Playing beside one another is parallel play and typical of toddlerhood. The nurse would explain this is normal behavior for the twins and then document the finding. The nurse would not need to observe the twins at play or ask additional questions as this is an expected finding.

What are the 10 most common medications involved in child poisonings?

1. Acetaminophen 2. Aspirin 3. Laxatives 4. Sedatives 5. Tranquilizers 6. Analgesics 7. Antihistamines 8. Cardiac medications 9. Cough/cold medicines 10. Birth control pills

Discuss nutritional concerns of the toddler and the progression of the toddler's self-feeding skills.

1. Slower growth rate 2. A drive for independence 3. Food jags 4. Variations in appetite - The toddler progresses from finger feeding and tilting the cup to being able to hold a spoon and handle a cup in an adult manner - Serve small portions - Fruit: 1-1.5 cups - 1-1.5 cups veggies - 3-5 oz grains - 2-4 oz. protein foods - 2-2.5 cups dairy

Describe physical growth and development that occurs during toddlerhood.

The toddler's physical growth SLOWS while motor, social, and language development RAPIDLY INCREASES Weight: Each year gains 4.5-6 lbs. Height: Each year gains about 3 in. Teeth: - Continued eruption of teeth, particularly molars. Motor Skills: - Learns to stand alone & walk between 1-2 yrs. - Ritualism: Follows routines for a sense of security GU: - Partial or total toilet training. Speech: - Say first words - Negativism: Says "No" to everything.

State why accident prevention is a primary concern and discuss 4 leading causes of accidental death of toddlers and preventative measures.

Accidents is the leading cause of death for children between ages of 1-4 yrs. 1. Motor vehicles 2. Drowning 3. Burns 4. Poisons * Tips: - Toddlers should always be secured in a car seat when in a motor vehicle. - Supervision is important when toddlers are near motor vehicles, streets, bathtubs, and swimming pools - Toxic substances should be stored out of reach and in childproof containers.

Identify important aspects of family teaching to be reinforced with the caregivers of toddlers, including (a) bathing b) dressing (c) dental care (d) toilet training (e) sleep

Bathing: - Avoid using bubble bath d/t bladder infections Dressing: - Want to dress themselves by 2 y/o - Encourage family to let dress themselves - Roomy clothing with easy buttons, large, smooth-running zippers, Velcro - Shoes to protect feet Dental Care: - Brush teeth or rinse mouth after meal use water until can spit - When using toothpaste, use one with fluoride to strengthen enamel - Dentist after 1 yr Toilet Training: - Bladder training ready when makes a connection between puddle on floor and something he/she did - If stays dry for about 2 hrs. at a time during the day, may indicate sufficient maturity - Toilet trained at night may not be achieved until 5 years of age Sleep: - 12-14 hrs. sleep for 2 years old - Decreases to 10-12 hrs by 3 years - Napping until approx. 3 yrs

When assessing a toddler's language development, what is the standard against which you measure language in a 2-year-old toddler?

- The toddler should speak in two-word sentences ("Me go"). Explanation: A toddler can understand language and is able to follow commands far sooner than he or she can actually use the words. By 2 years of age, a toddler typically speaks in two-word (noun and verb) sentences. Two-year-old toddlers have a vocabulary of about 40 to 50 words, and they start to use descriptive words (hungry, hot). The words "ma-ma" and da-da" occur much earlier than the toddler stage. The toddler is about 36 months of age before using pronouns or plurals in sentences. Children are unable to count to 20 until they are 5 to 6 years old.

The nurse is watching toddlers at play. Which normal behavior would the nurse observe?

- Toddlers engage in parallel play. Explanation: Toddlers typically play alongside another child (parallel play) rather than cooperatively. Infants engage in solitary play.

Parents and their nearly 3-year-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 Explanation: A child nearly 3 years of age should speak in three- to four-word sentences. The other findings indicate normal expressive language for the age.

The 18-month-old toddler has most likely attained which gross motor skill?

- The ability to walk independently. Explanation: The 18-month-old toddler can walk alone, but the gait may still be a little unsteady. By 3 years of age, the child can walk heel-to-toe fashion like an adult. The 18-month-old toddler can walk up the stairs with assistance but cannot walk stairs with alternate feet until 36 months. A 3-year-old child can pedal a tricycle and balance on one foot.

The nurse is assessing a toddler's fine motor skills. Which finding by the nurse could be a safety concern?

- Ability to turn door knobs Explanation: Turning knobs opens doors and may allow the child access to the outdoors or unsafe areas within the home. Close to follow will be the ability to unscrew lids, creating poisoning risks. The other abilities promote growth and development and involve lesser safety hazards.

The mother of a 2-year-old child tells the nurse that she is constantly scolding the child for having wet pants. The child was toilet trained at 12 months, but since walking, the child wets all of the time. Which nursing diagnosis should the nurse use to guide instruction for the mother?

- deficient parental knowledge related to inappropriate method for toilet training Explanation: The mother is having difficulty understanding the principles of toilet training. The diagnosis of deficient parental knowledge about toilet training is the most appropriate for the nurse to use to guide instruction for the mother. The child is not experiencing total urinary incontinence. The child does not have an excess in fluid volume. The mother is not demonstrating ineffective coping.

Parents share that their toddler often needs a snack in between meals. Which 3 snack choice is nutritious enough to give the toddler energy but also may help prevent dental caries?

- orange slices - cheese slices - yogurt Explanation: Toddlers often need between-meal snacks. To help prevent dental caries from frequent snacking, encourage parents to offer fruit (e.g., bananas, pieces of apple, orange slices) or protein foods (e.g., cheese, pieces of chicken) for snacks rather than high-carbohydrate items such as cookies and candy bars to limit exposure of the child's teeth to carbohydrates. Calcium (found in large amounts in milk, cheese, and yogurt) is especially important for the development of strong teeth

During a well-child visit to the health care provider, the parent reveals a family struggling with the changes from their "sweet, cuddly 16-month-old child" to that of a negative, more aggressive 2-year-old toddler. After the clinic visit, the nurse will document which priority nursing focus for this visit?

- ready for enhanced family coping Explanation: The most appropriate nursing focus would be that the family is ready for enhanced family coping related to the parents' ability to adjust to the new needs of the toddler. There is no indication that the other issues require a nursing action.

The parent of a 2-year-old boy has asked for some ideas for snack foods that would be less likely to cause dental caries. Which of the following items would the nurse most likely suggest?

- whole grain chips broken into pieces Explanation: Whole grain chips would be the least cariogenic snack. Fruit strips and raisins are both high in sugar and sticky, causing them to coat the teeth longer. Peanuts are not cariogenic, but present a choking hazard for a toddler.

Discuss important aspects of nursing care for the toddler in the health care facility.

Nutrition: 1. Reinforcing diet teaching 2. Childproofing the home Careful handwashing (before meals, after toileting) 3. Avoidance of rich foods GU/GI: - Observe for perianal itching (Scotch tape test, administer anthelmintic) - Teaching toileting procedures - Urinalysis when indicated (e.g., burning) Hygienic practices - use of tissue or handkerchief - not drinking from same glass - Teaching hygiene (at the onset of training, instruct girls to wipe from front to back, and wash hands to prevent cross-infection) Immunizations: - For passive immunity against communica- ble disease Dental: - Oral hygiene, regular tooth brushing, dental examination at 2.5-3 yrs Nutrition: - Proper nutrition to ensure dentition Sleep: - Teaching regarding recommended amounts of sleep (12-14 hrs in first year, decreasing to 10-12 hrs by age3) - need for rituals to enhance transition process to bedtime; possibility of need for nap; setting bedtime limits

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." Explanation: 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 other statements support good toddler nutrition. Whole milk is needed through age 2 years. Two cups daily is adequate. Nutritious snacks support quality intake when quantity is poor. New foods offered with old ones provide sameness along with the new.

The mother of a 3-year-old is considering the following purchases as a birthday present. Which toy would the nurse suggest as the most age appropriate choice?

- Pounding bench Explanation: The 3-year-old child should have a tricycle, large sturdy toys such as big blocks, active toys like a pounding bench, and musical toys that encourage rhythmic movement. The preschooler also likes show-and-tell, guessing games (because his or her memory is improving), and big-pieced jigsaw puzzles. For the 4-year-old, construction toys, jigsaw puzzles, memory games, and fantasy play are favorites.

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 Explanation: The child having a tantrum is out of control, making reasoning impossible. Calmly bear hugging the child provides control, especially in a public place. The other actions are helpful in preventing a tantrum.

Define the following terms as they relate to toddlers: (a) negativism b) ritualism c) dawdling (d) temper tantrums

Negativism: - opposition to suggestion or advice; associated with the toddler age group because the toddler, in search of autonomy, frequently responds "no" to almost everything Ritualism: - practice employed by the young child to help develop security; consists of following a certain routine; makes rituals of simple tasks Dawdling: - wasting time; whiling away time; being idle Temper Tantrums: - Behaviors in children that spring from frustrations caused by their urge for independence; a violent display of temper. The child reacts with enthusiastic rebellion against the wishes of the caregiver

Describe the psychosocial development of the toddler in relation to (a) Parallel play (b) discipline (c) the addition of a sibling to the toddler's home situation

Parallel Play: - one child plays alongside another child or children involved in the same type of activity, but the children do not interact with each other Discipline: - to train or instruct to produce self-control and a particular behavior pattern, especially moral or mental improvement. Timing & Consistency is needed to discipline children Addition of Sibbling: - Toddler regresses to more infantile behavior, Special preparation and parental attention is necessary to show that there is room in the parent's lives for both children.

The nurse is teaching the parents of a 2-year-old child how to handle the child's temper tantrums. The nurse determines that the teaching was successful if the parents make which statement?

- "We will ignore our child while having the tantrum." Explanation: The best response is to tell a child simply that the parent disapproves of the tantrum and then ignore it. Bribery, such as saying that the child can have a treat if the behavior stops, is rarely effective because by accepting the child's wishes, the parent is encouraging the child to have more tantrums because he or she was successful. Placing the child in time-out does not deal with the actual tantrum. When a child is placed in time-out, the appropriate length is 1 minute per year of age (2 minutes for this child). Tantrums are a result of the child not being able to appropriately express his or her needs, desires, or frustrations. It is not appropriate to attempt to reason with a upset 2-year-old child.

The mother of a toddler is frustrated because no matter what she asks of the child, the response is "no." What can the nurse suggest to the mother to assist with this problem?

- Give the child secondary, not primary, choices. Explanation: A toddler needs experience in making choices, and to provide the opportunity to do this, a parent could give a secondary choice. Pretending not to hear the child, asking no further questions, and telling the child to never say "no" again will not help with the toddler's obstinacy.

A mother of a 2-year-old girl is asking her friend when she should start potty training the child. The mother expresses concern about the high cost of diapers and training pants and would really like to have her trained as soon as possible. Which advice by the friend would be considered the best response?

- "When she is uncomfortable in her wet diaper and brings a clean diaper to you, that's a good indication she is ready for potty training." Explanation: The markers of readiness are subtle, but as a rule, children are ready for toilet training when they begin to be uncomfortable in wet diapers. They demonstrate this by pulling or tugging at soiled diapers, or they may bring a parent a clean diaper after they have soiled so they can be changed. Usually the child needs to walk well independently before training can occur.

A pediatric nurse is providing care to several children. The nurse is reviewing the assessment findings for each of the children. Which finding requires the nurse to intervene?

- 3-year-old preschool-aged child who goes up stairs on hands and knees Explanation: At 3 years of age, a child should be able to climb the stairs one step up at a time or using alternating feet. If the child can only go up on hands and knees, further evaluation is needed. At 9 months of age, an infant can pull oneself up to a standing position and sometimes is able to cruise around furniture or even walk. Toddlers begin to walk between 9 and 18 months of age. Toddler at 24 months of age engage in parallel play rather than cooperative play.

The parent of a 2-year-old toddler tells the nurse she needs to constantly scold the toddler for having wet pants. The parent says the toddler was potty trained at 12 months, but since starting to walk, the toddler wets the pants all the time. Which nursing diagnosis would be most applicable?

- Deficient parental knowledge related to inappropriate method for toilet training Explanation: Myelination of the spinal cord is achieved around 2 years of age. When this occurs, the toddler can exercise voluntary control over the sphincters. It is probable that a toddler toilet trained at 12 months of age was not truly trained, because the infant would not be developmentally able to complete the task. It is most likely the parent used a training method of reminding the infant or placing the infant on a toilet frequently during the day. When the toddler begins to play independently, the toddler forgets the regimented schedule. This toddler is not toilet trained independently. The toddler does not display total urinary incontinence. The toddler is only incontinent when playing and not reminded to potty. A 2-year-old toddler has limited coping skills. Frequent wetting of the pants does not indicate too much fluid intake. It is a symptom that the toddler does not feel the urge to urinate until the bladder is too full and the toddler cannot get to the toilet on time.

A 13-month-old child is brought to the clinic for a well-child visit. The child's parent expresses concern that the child has not started to walk yet. What is the best action should the nurse take?

- Explain that children can take their first steps as late as 18 months of age. Explanation: Infants can begin walking as early as 8 to 9 months and as late as 18 months of age. Telling the parent that the child will start walking any day is true but not guaranteed. Asking if the child has been ill recently is an appropriate question during a well-child visit but does not address the parent's concerns. Since the child is on track developmentally, there is no indication to refer the child to a developmental specialist.