Chapter 26Growth and Development of the Toddler

Separation (Emotional and Social Development)

Seeing oneself as separate from the parent.

Toddler Piaget

Sensorimotor and preoperational.

Parents are proud of their toddler's fast-developing fine motor skills. Which skill should the nurse point out as a safety risk? Hold crayon to write. Ability to turn knobs. Turn book pages. Put shapes into matching openings.

Ability to turn knobs. 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.

Toddler Erikson

Autonomy vs shame and doubt

Weight increases steadily in spurts

Average weight gain = 3 to 5 lb per year

What statement by the parent of a 20-month-old indicates a need for further teaching about nutrition? "New foods are offered along with ones my child likes." "I give my child juice at breakfast and when my child is thirsty during the day." "When my child doesn't eat well at meals we give nutritious snacks." "My child drinks three 6-ounce cups of whole milk each day."

"I give my child juice at breakfast and when my child 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 nurse is reviewing sleep and rest activities of a 16-month-old child with the parents. The parent states, "I have told my spouse it is unhealthy for our child to sleep with us. It's time for the child to sleep in one's own bed. What do you think?" What is the nurse's best initial response? "Co-sleeping is viewed acceptable by some professionals, but interfering with the child's independence by others." "I will note this in your child's chart for the healthcare provider to see." "Have you thought about just trying to let your child sleep in one's own bed to see how it goes?" "It must be difficult for the two of you to both feel strongly about what is best for you and your child."

"It must be difficult for the two of you to both feel strongly about what is best for you and your child." Acknowledging the struggle between the mother and father allows for open conversation about the sleeping arrangement, which may lead to an acceptable resolution.

The nurse is teaching parents how to avoid a power struggle with their 2-year-old child. Which comment indicates that more teaching is needed? "We will give our child a choice whenever possible." "We will make sure our child shares toys with cousins of this age." "Childproofing our home will make it less necessary to say 'No!'" "Both of us, as parents, will agree on and consistently enforce the limits we set."

"We will make sure our child shares toys with cousins of this age." A 2-year-old's thinking is not mature enough to include the concept of "sharing." The child sees situations from a child's point of view (egocentrism). That makes sharing with another beyond what the child can accept as an understandable action.

Play (Toddler)

*Major socializing medium at this age* -Egocentric -Do not like to share

Toddler physiologic changes of the respiratory system

-Alveoli continue to increase in number -Trachea and airways remain small compared to adult -Tonsils and adenoids are relatively large

Length/height increases steadily in spurts

-Average increase 3 in per year -About ½ adult height by age 2

Provide a safe home environment

-Avoid tobacco smoke exposure -Water safety (careful observation) -Prevent injury -Prevent poisoning *Increasing mobility REQUIRES increased vigilance.*

Toddler physiologic changes of the GU system

-Bladder and kidney reach adult function by 16 to 24 months -Bladder capacity increases -Urethra remains relatively short

Promoting Self-Feeding

-Child-sized spoon and f*ork with dull tines* -Appropriate portion size, type, and texture of the food -Seat the toddler in a high chair or at a comfortable height in a secure chair. -Include the toddler in family mealtimes; praise attempts at self-feeding. -*Never leave the toddler unattended* while eating -Minimize distractions during mealtime

Individuation (Emotional and Social Development)

-Forming a sense of self -Learning to control one's environment -Leads to emotional lability

Toilet Teaching Readiness Signs

-Has regular bowel movements (usually after 2 years old). -Expresses knowledge of need to defecate or urinate -Diaper is not always wet -Willing to follow instructions -Walks well alone -Can pull down pants -Follows caregiver to bathroom -Climbs onto potty chair or toilet

Toddler sensory Development

-Hearing intact since birth -Visual acuity continues to improve -May prefer certain smells -May prefer certain textures (soft vs. scratchy clothes) -Explore environment with all five senses!

Toddler physiologic changes of the cardiovascular system

-Heart rate decreases -Blood pressure increases

Common Toddler Developmental Concerns

-Weaning to cup -Thumb sucking and pacifiers -Negativism -Temper tantrums -Toilet teaching -Sibling rivalry -Aggression and regression

Urine output should be about

1 mL/kg/hr

3yr old sleep requirements

12 hours of sleep per day

24 month old sleep requirements

13 hours of sleep per day

18 month old sleep requirements

13.5 hours of sleep per day

Anterior fontanel closes by

18 months.

Toddler vision continues to progress and should be

20/50 to 20/40 in both eyes.

Pepsin production matures by

2yrs

Infant brain is adult size by age

2yrs.

May discontinue daytime napping around

3yrs.

The alveoli continue to increase in number, not reaching the adult number until about

7yrs

When to use fluoride toothpaste>

A Using fluoride toothpaste prior to age 2 years promotes development of fluorosis.

The nurse is providing parental anticipatory guidance to promote healthy emotional development in a 12-month-old child. Which statement best accomplishes this? Emotions of a 12-month-old are labile. He can move from calm to a temper tantrum rapidly. A regular routine and rituals will provide stability and security. A sense of control can be provided through offering limited choices. Aggressive behaviors such as hitting and biting are common in toddlers.

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. Knowing that a child can move from calm to temper tantrum very quickly, understanding the benefit of limited choices, and realizing that hitting and biting are common behaviors in toddlerhood provide information but not a guiding concept.

Toddler Freud

Anal stage

Examples of dietary fiber

Applesauce, carrots, corn, green beans, mangos, pears.

Vitamin A examples

Apricots, carrots, cantaloupe, mangos, spinach, dark greens, sweet potatoes.

The nurse is promoting language and cognitive development to the parents of a 3-year-old child. Which guidance about reading with their child will be most helpful? Keep story time a reward for being good. Read a different book if he knows the story. Have the child sit still during the story. Ask the child questions as you read.

Ask the child questions as you read. Engage the child by asking him questions as he listens. This gives him a chance to contribute to the story.

Echolalia

Automatic and immediate repetition of what others say.

The parent of a preschooler reports that the child seems to believe in magic. The parent voices concern that this "fantasy world" may become a problem. What response by the nurse is indicated? (Select all that apply.) A. "While imagination is normal, this type of fantasy world can cause problems for your child and should be discouraged." B. "This type of thought process allows your child to begin to observe the differences in the world." C. "Your child is engaging in what we call magical thinking." D. "This type of imagination is not normally seen until a child is school aged." E. "Fantasy play is most often seen in lonely children in an attempt to occupy themselves."

B, C

The nurse is assessing a 2-year-old toddler. Which observations would alert the nurse that the child may be developmentally delayed? (Select all that apply.) A. The child is unable to stack one block on top of another. B. The child will not pick up a toy or touch the nose when directed by the nurse. C. The child's vocabulary consists of the words "ball," "dada," "mum," "drink" and "up." D. The child pushes and pulls the play vacuum cleaner in the toy room. E. The child claps hands in response the nurse clapping hands.

B, C The 2-year-old toddler should be speaking in 2-word sentences, and should be able to follow simple commands. Imitating the clapping of hands and pushing and pulling objects is expected of a 2-year-old toddler. The child should not be able to stack blocks until the age of 3, so this observation would not be a concern at this age.

A stay-at-home parent wants to purchase commercial toddler meals because the 16-month-old child recently choked on table food. Which food items will the nurse suggest not be given to this child? (Select all that apply.) A. Vegetables such as corn, green beans, and peas B. Hard foods such as nuts, raw carrots, and popcorn C. Round foods such as hot dogs, whole grapes, and cherry tomatoes D. Fruits such as peaches, pears, and kiwi E. Sticky foods like peanut butter alone, gummy candies, and marshmallows

B, C, E To offer soft round foods safely, cut hot dogs in uneven pieces and quarter grapes and cherry tomatoes. This prevents food impacting in an airway. Avoid the hard and sticky foods due to aspiration and airway occlusion risks. The cooked vegetables listed are safe as are the soft fruits.

Telegraphic speech

Early speech stage in which a child speaks like a telegram—"go car"—using mostly nouns and verbs.

Fluorosis is caused by:

Excessive fluoride intake resulting in irreversible staining of the teeth.

Is the following statement true or false? A colorful simple board game that requires multiple players to cooperate with each other for a common goal would be the best type of toy for toddlers.

False. Toddlers tend to engage in parallel, solitary play and are not likely to cooperate in a group game situation because of their basic egocentric nature. Rationale: The best toys for toddlers are familiar household items, child-size household items, blocks, cars, plastic figures, stuffed animals, dolls, doll beds, and carriages. Manipulative toys with knobs and buttons that make things happen, shapes to insert into matching holes, puzzles, chalk, buckets and shovels, and floating toys are also recommended. Appropriate gross motor toys include gyms, tricycles, pull toys, and wagons.

Receptive language

Far more advanced in early toddlerhood than expressive language.

Egocentrism (Emotional and Social Development)

Focus on self.

The nurse is teaching the parent of a 2-year-old child about age-appropriate toys. Which would be of most interest plus stimulating to the growth and development of this child? Offering the child a variety of large stuffed toys. Giving the child bowls, pot, pans, and large spoons. Giving the child a toy vacuum cleaner. Providing a brightly colored plastic bucket and shovel.

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.

A parent reports her 2-year-old daughter has gradually eaten more and more poorly since her 1-year-old well-child visit. The nurse assesses the child's growth and development as normal. What concept explains the parent's concern? Physiologic anorexia Iron-deficiency anemia Poor role modeling Improper snacking

Physiologic anorexia. Physiologic anorexia results when the rapid growth of infancy slows in toddlerhood and less food is required for body size.

The nurse is discussing proper discipline with the parent of a 15-month-old child. Which statement is most important? Never spank the child for any reason. Toddlers are unable to learn rules easily. Use praise when the child is doing something right. Rules and limits should be simple and few.

Never spank the child for any reason. Toddlers younger than 18 months of age should not be spanked due to the possibility of injury.

The parents of a 2-year-old child report to the nurse because their child is "such a picky eater." Which recommendation would be most helpful for developing healthy eating habits in this child? Advising the parents to minimize distractions at mealtime. Offering a variety of foods along with the foods the child likes. Encouraging the parents to eat a variety of wholesome foods themselves. Assuring the parents that food jags are normal, and they can be honored safely.

Offering a variety of foods along with the foods the child likes.

The nurse is recommending food items for an 18-month-old child. Which ones will benefit the child's neurologic system most? Vegetable soup, whole wheat bread, and blueberries. Peanut butter on crackers, cheese, and whole milk. Ground beef, broccoli, and apple slices. Oatmeal pancakes with bananas.

Peanut butter on crackers, cheese, and whole milk. At 18 months, the child's neurologic system is still developing rapidly and needs dietary fat for myelinization. Peanut butter on crackers, cheese, and whole milk all provide this.

The nurse is visiting a day care center and watches two toddlers at play. What best describes the play observed? Playing alongside one another. Playing for significant stretches of time in one activity. Sitting quietly with several toys. Sharing stuffed animals.

Playing alongside one another. This is parallel play.

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? Made sure the child was rested and not hungry before going to the mall. Remained relatively calm even though embarrassed. Tried to refocus the child's attention as tantrum behavioral cues appeared. Reasoned with the child to stop the behavior.

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

Parents who just moved into their "dream home" are concerned because their toddler, who had achieved daytime bowel and bladder control, has begun wetting and defecating in the underwear. The nurse explains this is called: Egocentrism Ritualism Regression Autonomy

Regression. He is returning (regressing) to an earlier, possibly safer stage of development caused by a stressor (moving).

The nurse is examining a 3-year-old child during a regular visit. Which finding would disclose a developmental delay in this child? The child copies a circle on a piece of paper. The child follows directions when made one at a time. The child imitates the nurse in use of a stethoscope. The child demonstrates separation anxiety.

The child demonstrates separation anxiety. The child should be past the stage of separation anxiety by age 3 years.

he nurse is examining a 2-year-old child for speech and language development. Which finding would suggest a delay in speech development? The child puts together sentences of two words. The child repeats what the parents say out of context and at random moments. The child does not speak clearly but shows understanding of what is said. The child does not use the names of familiar objects.

The child does not use the names of familiar objects. By 24 months most children will name objects familiar to them in their daily lives. Not doing so is strong evidence that a speech delay may exist. Repeating words heard or phrases out of context (echolalia) is normal and a way to practice words and incorporate them in the vocabulary. At 2 years, most children understand much more than they can clearly repeat. Using two-word sentences is a developmental expectation at this age.

In discussing with the nurse their 2-year-old's behavior, which of the parents' descriptors suggests the child may be ready for toilet teaching? The child hides behind her bedroom door when defecating. The toddler walks with a wide, swaying gait. The child often removes her shoes and socks. The child frequently repeats words parents just said.

The child hides behind her bedroom door when defecating. Hiding while defecating indicates awareness of this need.

The nurse is assessing speech development in the 2-year-old whose family uses both Spanish and English in the home. What finding is of concern? Some words the toddler speaks are a blend of English and Spanish. The toddler speaks 15 words between the two languages. The child mixes words from the two languages within a sentence. The parents understand the child much of the time.

The toddler speaks 15 words between the two languages. Of concern is speaking only 15 words between Spanish and English. At 20 months, the bilingual child should use 20 words.

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? Asks "why" often. Uses two-word sentences or phrases. Talks about a past event. Half of speech understood by outsider.

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

Food jags

When a child will only eat the same food meal after meal.

Head size more proportional to body by ______.

age 3.

The nurse praises a 3-year-old child for using the potty. Which of the following theorists focuses on the satisfaction/frustration of expelling feces? a. Piaget b. Freud c. Erickson d. Kohlberg

b. Freud Freud's theory focuses on the satisfaction and/or frustration of expelling feces (anal stage). Rationale: Piaget's theory focuses on development of the senses of the toddler; Erickson's theory focuses on achievement of autonomy and self-control; Kohlberg's theory focuses on the moral development of the toddler.

The nurse is planning a diet for a toddler that is rich in vitamin A. Which of the following foods might the nurse include? a. Avocados b. Corn c. Strawberries d. Carrots

d. Carrots. Carrots are rich in vitamin A. Rationale: Avocados are rich in folate, corn is rich in fiber, and strawberries are rich in vitamin C. Other foods rich in vitamin A include apricots, cantaloupe, spinach, mangos, dark greens, and sweet potatoes.

Gross Motor: Toddlers

-Initial walking with "toddler" gait -Pushing or pulling a toy *Later includes:* Running Climbing Jumping Throwing a ball Pedaling a tricycle

Choosing a Preschool

-Is child developmentally ready? -Staff training: Early childhood development, CPR. -Appropriate adult-to-child ratio. -Disciplinary procedures are consistent with the parents' values. -Parents are able to visit at any time. -School is childproofed inside and out. -Appropriate hygiene procedures are in place.

Minimizing Sibling Rivalry

-Keep the toddler's routine as close to normal as possible. -Minimize other changes in the household, if possible. -Spend individual time with the toddler on a daily basis. -Involve the toddler in the care of the baby

Toddler Discipline

-Limit setting -Negotiation -Techniques to assist the toddler to learn problem solving -Offer realistic choices -Keep instructions simple -Reinforce desirable behaviors -Extinction and "Time-outs" for negative behaviors

Daily playtime ranges from 30-60 minutes. A suitable measure for appropriate interactions might be

-Limit television -Encourage creative and physical play -Toys that engage multiple senses

Parents as the First Teachers

-Model social behaviors and gender roles. -Facilitate language development by talking to and reading with the child. -Convey family cultural traditions and spiritual values. -Provide emotional and psychological safety.

Toddler physiologic changes of the Musculoskeletal system

-Muscles maturing -Swayback and pot belly until 3 years old

Fine motor: Toddlers

-Progresses from holding and pinching -Manages utensils -Holds crayon -Strings a bead -Works a puzzle -Uses a touch screen

Typical Toddler Behaviors

-Security item -Gender difference awareness -Aggressive behaviors -Unclear body boundaries (becomes more self-aware, resists invasive procedures) -May fear: Strangers, Loss of parents, Separation anxiety may reoccur.

Toddler physiologic changes of the GI system

-Stomach increases in size -Small intestine grows in length -Less frequent stools—color varies with diet -Bowel control typically achieved by end of toddler period

Physiologic anorexia

A decrease in appetite manifested when the extremely high metabolic demands of infancy slow to keep pace with the more moderate growth rate of toddlerhood.

The parent of a toddler half-jokingly states: "I am so tired of hearing 'NO!' I wish he would stop!" What suggestions will the nurse offer to reduce toddler negativism? (Select all that apply.) A. Avoid ending a request with "Okay?" B. Avoid "yes" and "no" questions. C. Emphasize what is not to be done: "Don't sit there." D. Make statements: "It is time for lunch." E. Use humor to make "no" funny: "Do cows bark?" F. Offer simple choices: "Blue shirt or red one?"

A, B, D, E, F

The nurse is playing a game with a toddler in the hospital room. What is the most important benefit of this nurse--client interaction? Utilizing clinical time when the unit is not busy. Occupying the toddler's time while the parents are meeting with the health care provider. Developing a trusting relationship with the nurse. Distracting the toddler from expending too much energy with active playing.

Developing a trusting relationship with the nurse.

The student nurse is assigned to care for a 15-month-old child. When developing a care plan addressing the nutritional needs of the toddler, which client goals demonstrate the student nurse's understanding of these needs? (Select all that apply.) A. "The child will drink amounts suggested by the pediatrician of milk and other fluids on a daily basis." B. "The child will drink milk from a bottle every day for the next 2 months." C. "The child will stop drinking from a bottle while in bed within the next 2 weeks." D. "The child will be weaned from breastfeeding within the next month." E. "The child will learn to drink from a cup within the next month."

A, C, E. A 15-month-old toddler should be drinking fluid (other than breast milk if still breastfeeding) from a cup because extended bottle feedings at any time of day promote dental caries at this age. Most professional organizations suggest that infants be breastfed for at least 12 months. Breastfeeding beyond 12 months provides nutritional, immunologic, and emotional benefits to the child.

Parallel play

Activity in which children play side by side without interacting.

Folate examples

Avocados, broccoli, green peas, oranges, spinach, dark greens, strawberries.

Vitamin C examples

Broccoli, green peas, cantaloupe, oranges, strawberries, potatoes, tomatoes.

Which suggestion by the nurse meant to promote good dental health in the 15-month-old is inappropriate? Brush your child's teeth with a pea-sized amount of fluoride-containing toothpaste. Avoid grazing (continual snacking) throughout the day. Arrange for your child's first dental visit as soon as possible. Wean the child from the bottle.

Brush your child's teeth with a pea-sized amount of fluoride-containing toothpaste. Using fluoride toothpaste prior to age 2 years promotes development of fluorosis.

The nurse finds the diet of a 30-month-old child to be low in calcium. What suggestion can significantly increase this toddler's calcium intake? Include dark greens and spinach in her meals. Offer chocolate milk to increase milk intake. Use unsweetened applesauce as a dessert. Give her slices of cheddar cheese as a snack.

Give her slices of cheddar cheese as a snack. Two and one-half ounces of cheddar cheese provides the toddler's daily requirement of 500 mg of calcium. Chocolate milk provides calcium but the sugar it contains should not be a regular part of a toddler diet. Applesauce provides fiber, not calcium. Spinach and dark greens do contain calcium, but that calcium has limited bioavailability.

A parent expresses surprise to the nurse that her toddler daughter has begun masturbating. The most important initial nursing response is: Check for undue stress in your toddler's life. This is a normal and expected activity best treated matter-of-factly. Toilet teaching places much focus on the genitals. Toddler girls as well as boys will masturbate.

This is a normal and expected activity best treated matter-of-factly. Masturbation is a normal event to be done in private. Calling attention to the behavior may increase the frequency. Both girls and boys masturbate, and toilet teaching calls attention to the genital area. These two statements are accurate information but not the best first response. Excessive or public masturbation points to stress.