Chapter 26
The nurse is examining a 2-year-old girl for speech and language development. Which finding would suggest a delay in speech development? A) The child does not use the names of familiar objects. B) The child puts together sentences of two words. C) The child repeats what the parents say out of context and at random moments. D) The child does not speak clearly but shows understanding of what is said.
A 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. Page 998
A 15-month-old toddler has been brought to the clinic because the toddler is pale and listless. Which finding or observation would lead the nurse to suspect iron-deficiency anemia as the cause of the clinical manifestations? A) The toddler drinks 32 oz (1 L) of milk per day. B) The nurse hears a grade 2 heart murmur. C) The toddler drinks very little fruit juice. D) The toddler eats a vegetarian diet.
A Cow's milk is low in iron content. It should be limited to 16 oz (0.5 L) per day in toddlers. This toddler is drinking 32 oz (1 L) of milk per day, which can contribute to iron-deficiency anemia. A good vegetarian diet would not cause the toddler's symptoms. Generally vegetarian diets are more deficient in vitamins D and B12. The grade 2 heart murmur is most likely innocent. Eating an acidic fruit or drinking the juice with iron-containing foods enhances iron absorption. Page 1007
A parent tells the nurse that no matter what is asked of the toddler, the toddler says, "No." What suggestion might the nurse make to help the parent handle this situation? A) give the toddler secondary, not primary, choices B) ask no further questions of the toddler C) pretend the parent does not hear the toddler's response D) tell the toddler never to say, "No" again
A Encouraging toddlers to express their opinion aids in developing a sense of autonomy. By allowing secondary choices, it gives the toddler a sense of mastery. Telling the toddler not to say "No" again is unrealistic as this is a favorite word and reaction of the toddler as he or she develops autonomy and find one's "self." Pretending not to hear the toddler only leads to more frustration for the toddler and the parent. It is also unrealistic not to ask the toddler questions. There would not be two-way communication between the parent and the toddler. Page 1013
The parents of a 2-year-old child born with short-gut syndrome feed their toddler via a feeding tube. Knowing this is a developmental time when children usually feed themselves, the parents are asking the nurses what they can do to help foster the child's independence. Which suggestion would be most appropriate at this time? A) Let the child choose what clothing he or she will wear the next day. B) Try to focus the child's energy on learning to read simple books that are age appropriate. C) Imitate placing food in the child's mouth as long as the food is large enough so it cannot be swallowed. D) Play catch with the child while others are eating so they do not have to feel left out.
A If children are tube fed, they receive no experience at all with finger foods. For these children, parents should try to provide other, comparable experiences in independence, such as letting them choose what toy to take to bed or what clothing to wear. Playing, reading, or pretending a toy is food at feeding time are not appropriate activities since the child's feeding is usually scheduled around normal meal times.
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: A) object permanence. B) mental combinations. C) concrete thinking. D) preoperational thinking.
A Object permanence means that the child knows that objects that are out of sight still exist. Page 995
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? A) Readiness for enhanced family coping B) Disabled family coping C) Potential risk for child abuse D) Impaired resilience
A The most appropriate nursing focus would be readiness for enhanced family coping related to the parents' ability to adjust to the new needs of the toddler. There is no indication the scenario presented that the other issues require a nursing action.
A mother is concerned because her 14-month-old son, who had a big appetite when breast-feeding a few months ago, seems uninterested in eating solid food. She still breast-feeds him daily, but is thinking of weaning him soon. How should the nurse respond to this mother? A) "It is normal for toddlers to lose their appetites; try weaning him all at once so that he will be more interested in the solid food." B) "It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate." C) "It is not normal for toddlers to lose their appetites; spoon feed him yourself to make sure he gets proper nutrition." D) "It is not normal for toddlers to lose their appetites; have him tested for a gastrointestinal condition."
B Because growth slows abruptly after the first year of life, a toddler's appetite is usually less than an infant's. Children who ate hungrily 2 months earlier now sit and play with their food. It is important to educate parents while the child is still an infant this decline in food intake will occur so they will not be concerned when it happens. Because the actual amount of food eaten daily varies from one child to another, teach parents to place a small amount of food on a plate and allow their child to eat it and ask for more rather than serve a large portion the child cannot finish. One tablespoonful of each food served is a good start. The nurse should recommend that the mother wean her son gradually to avoid confrontation, not all at once. Most toddlers insist on feeding themselves and generally will resist eating if a parent insists on feeding them. Page 1019
The nurse is promoting language and cognitive development to the parents of a 3-year-old boy. Which guidance about reading with their child will be most helpful? A) Keep story time a reward for being good. B) Ask the child questions as you read. C) Read a different book if he knows the story. D) Have the child sit still during the story.
B Engage the child by asking him questions as he listens. This gives him a chance to contribute to the story. The child does not have to sit still. He may want to move around or even act out part of the story. Story time should happen regularly and not be just a reward. Even if the child can tell the story, he may wish to hear it read again because he enjoys the repetition and familiarity. Page 1004
The nurse is providing parental anticipatory guidance to promote healthy emotional development in a 12-month-old boy. Which statement best accomplishes this? A) Emotions of a 12-month-old are labile. He can move from calm to a temper tantrum rapidly. B) A regular routine and rituals will provide stability and security. C) A sense of control can be provided through offering limited choices. D) Aggressive behaviors such as hitting and biting are common in toddlers.
B 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. Page 1001
A nurse, who is also a mother of a 2-year-old child, attends a party at a friend's house and notes some safety concerns that she would like to share with the other mother privately. Which observations during the party would be considered a safety concern that should be addressed privately when appropriate? Select all that apply. A) The safety gate/fence surrounding the pool area is secure and a little hard, even for parents, to unlatch. B) The parent is busy entertaining guests and did not notice the toddler running out in the neighborhood street to get a toy. C) The nurse/mother notes that the toddler's car seat is located in the passenger front seat. D) The parents allow the toddler to climb up on the counter and watch as food is stirred on the stove. E) Only toddlers with helmets on are allowed to ride the tricycle.
B, C, D Toddlers' motor ability jumps ahead of their judgment. To prevent serious injury, the nurse should teach parents to be alert as to what their toddler is doing at all times (like climbing on a countertop next to a stove). Toddlers have no judgment concerning moving cars so they walk across streets with no regard for oncoming cars. Toddlers need to ride in a car seat with a five-point restraint placed in the back seat (not the front seat) so the child is not struck by the passenger seat airbag. Toddlers need to wear a helmet as soon as they begin riding a tricycle. Because they cannot swim well, parents need to check whether backyard pools—another area prone to unintended injury—are securely fenced.
The parents of a toddler ask the nurse about disciplining their son. What suggestions would be most helpful? Select all that apply. A) "You need to wait until he is old enough to understand what you are asking." B) "It's better to praise correct behavior than to punish wrong behavior." C) "Avoid using physical punishment unless your son's behavior is really out of line." D) Increase the time spent in time-out, assigning one minute per child's age E) "It is important to have a consistent caregiver to prevent acting out from separation."
B, D Parents should begin to instill some sense of discipline early in life because part of it involves safety limits. Two general rules to follow include the need to be consistent and the use of praise for correct behavior rather than punishment for wrong behavior so that the child can learn the rules. Timeout is an effective technique to help children learn that actions have consequences. One minute per year of child's age is the common standard. Physical punishment is not recommended. Having a consistent caregiver is important for reducing separation anxiety. Page 1012
A group of caregivers of toddlers are discussing the form of discipline in which the toddler is placed in a "time-out" chair. Which statement made by these caregivers is most appropriate related to this form of discipline? A) "Our time-out chair is in the master bedroom so she cannot see anyone else in the family." B) "She is 2 years old now and I put her in time out for 5 to 10 minutes when she misbehaves." C) "When my son starts getting frustrated and aggressive, I remind him that if he throws a fit he will have to go to time out." D) "We use the time-out chair when our son gets tired but does not want to take a nap."
C A method for a toddler who is not cooperating or who is out of control is to send the child to a "time-out" chair. This should be a place where the toddler can be alone but observed without other distractions. The duration of the isolation should be limited—1 minute per year of age is usually adequate. Caregivers should warn the toddler in advance of this possibility, but only one warning per event is necessary. The chair should be used for discipline not because the toddler will not go take a nap. It can be used for all ages of children. Page 1012
When assessing a toddler's language development, what is the standard against which you measure language in a 2-year-old toddler? A) The toddler should say two words plus "ma-ma" and "da-da." B) The toddler should say 20 nouns and 4 pronouns. C) The toddler should speak in two-word sentences ("Me go"). D) The toddler should be able to count out loud to 20.
C A toddler can understand language and is able to follow commands far sooner than 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 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. Page 998
The nurse is talking to the parent of a 19-month-old toddler about setting limits and supervising activities. In which situation will the nurse recommend letting the toddler do as he or she pleases? A) Deciding one's bedtime schedule B) Choosing one's own foods C) Exploring one's body D) Playing on the picnic table
C Children learn about gender differences during the toddler years. They observe differences between male and female body parts if they are exposed to seeing it. They question their parents about the differences. It is normal for toddlers to explore their genitals as they develop their own sense of self. The parent should allow this and not punish the child. Choosing food and deciding bedtimes need to be done by an adult. Likewise, safety dictates that the picnic table is not a safe play area. Page 999
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? A) Teach the mother that this larger head than body appearance will be this way until the child is about 6 years old. B) Explain that the child looks normal. C) Share that the heads of children at this age are large in proportion to the rest of their body. D) Some children have large heads but that does not signal a problem.
C 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. Page 993
The parent of a 2-year-old toddler tells the nurse needing 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? A) Ineffective coping related to lack of self-control of 2-year-old toddler B) Excess fluid volume related to inability to control urination C) Deficient parental knowledge related to inappropriate method for toilet training D) Total urinary incontinence related to delayed toilet training
C 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 toliet 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 toliet on time. Page 1013
In working with the toddler, which statement would be most appropriate to say to the toddler to decrease the behavior known as negativism? A) "You love having the same food every day. Do you want apples again with lunch?" B) "Do you want help getting into your chair so we can have lunch?" C) "It is time for lunch. I am going to put your bib on." D) "Are you getting hungry and ready for lunch?"
C Negativism is very typical of the toddler years. It is best to avoid questions with a yes or no answer because the answer will always be no. Limiting the number of questions asked of the toddler and making a statement, rather than asking a question or giving a choice, is helpful in decreasing the number of negative responses from the child. Instead of asking questions like "do you want help getting in your chair" make the statement "get in your chair." The toddler years are also ones where the child becomes a picky eater or "grazes" instead of eating a full meal so the toddler may not actually know if he or she is hungry. Page 1014
The parents of a 30-month-old toddler have brought the toddler into the emergency department because of a seizure. During the health history, the nurse suspects the toddler had a breath-holding spell. Which parental report suggests breath-holding? A) The toddler became unconscious. B) The toddler was lethargic afterward. C) A tantrum preceded the event. D) The event took place during a nap.
C Temper tantrums are the natural result of frustrations that toddlers experience. They continue to occur until the toddler is old enough to verbalize feelings. 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. Unconsciousness is not definitive because it is common to both seizures and breath-holding spells. Page 1014
A 2-year-old toddler holds the breath until passing out when the toddler wants something the parent does not want the toddler to have. The nurse would base evaluation of whether these temper tantrums are a form of seizure on the basis that: A) seizures rarely occur in toddlers. B) seizures typically occur with fever; temper tantrums do not. C) seizures are not provoked; temper tantrums are. D) with seizures, cyanosis rarely develops.
C Temper tantrums are the natural result of toddler frustration. Toddlers are eager to explore new things but their efforts can be thwarted, especially for safety reasons. Toddlers do not behave badly on purpose. Temper tantrums occur out of anger and frustration. Seizures do not. Seizures can occur at any age. The client may or not be febrile. Depending upon how long a seizure lasts, cyanosis can occur. Page 1014
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? A) Made sure the child was rested and not hungry before going to the mall B) Remained relatively calm even though embarrassed C) Reasoned with the child to stop the behavior D) Tried to refocus the child's attention as tantrum behavioral cues appeared
C 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. Page 1014
The nurse is examining a 3-year-old girl during a regular visit. Which finding would disclose a developmental delay in this child? A) The child imitates the nurse in use of a stethoscope. B) The child copies a circle on a piece of paper. C) The child demonstrates separation anxiety. D) The child follows directions when made one at a time.
C The child should be past the stage of separation anxiety by age 3 years. Imitating actions, copying a circle on paper, and responding to single requests are developmentally appropriate. Page 1000
The father of a 2-year-old girl tells the nurse that he and his wife would like to begin toilet training their daughter soon. He asks when the right time is to begin this process. What should the nurse say in response? A) "The best time to start toilet training is as soon as the child begins walking." B) "She's well past the age to begin toilet training; most children are ready by age 1, when they have developed the needed nervous system control." C) "When she starts tugging on a wet or dirty diaper, she is letting you know she's ready." D) "It is best to wait a little longer, until she is 3; only then will she be socially developed enough to understand what you are asking her to do."
C 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. Because physiologic development is cephalocaudal, the rectal and urethral sphincters are not mature enough for control in most children until at least the end of the first year, when tracts of the spinal cord are myelinated to the anal level. A good way for a parent to know a child's development has reached this point is to wait until the child can walk well independently. Toilet training need not start this early, however, because cognitively and socially, many children do not understand what is being asked of them until they are 2 or even 3 years old. Page 1013
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? A) "I started training my kids when they started to pull themselves up to a standing position." B) "You will just have to condition yourself to take her to the potty chair every hour until they get the hang of it." C) "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." D) "It doesn't hurt to start when they turn 2 as long as you don't punish them for having many accidents."
C 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. The other answers do not address this. Usually the child needs to walk well independently before training can occur.
A nurse is assessing a 2-year-old's language development. What would the nurse expect to assess? A) Ability to name one color B) Knowledge of full name C) Verbalization of 4 to 6 words D) Use of a two-word noun-verb sentence
D A 2-year-old should be able to say a two-word sentence that consists of a noun and verb. A 15-month-old can say 4 to 6 words. A 30-month-old knows his full name and can name one color. Page 997
During the toddler years, the child attempts to become autonomous. Which statement by a 3-year-old toddler's caregiver indicates that the toddler is developing autonomy? A) "My toddler has temper tantrums when we go to the store." B) "When my toddler falls down, he or she always wants me to pick him or her up." C) "Every night my toddler follows the same routine at bedtime." D) "My toddler uses the potty chair and is dry all day long."
D During the toddler years, the toddler separates from his or her parents, recognizes one's own individuality and exerts autonomy. Being toilet trained is an example of the toddler developing autonomy or independence. Having temper tantrums is a normal response of the toddler as it is a way the toddler expresses frustration of being tired or not being able to accomplish a task. Having the parent pick up the child after the child falls is a security and emotional need. All children need this, so it is not indicative of toddlerhood or autonomy. Having the same routine for bedtime each night provides security but it does not demonstrate autonomy. Page 1014
The nurse is observing a 3-year-old boy in a day care center. Which behavior might suggest an emotional problem? A) Goes from calm to tantrum suddenly B) Sucks his thumb periodically C) Is unable to share toys with others D) Has persistent separation anxiety
D 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. Emotional lability, self-soothing by thumb sucking, or the inability to share are common for this age. Page 1000
What advice should the nurse provide the parent of a toddler, regarding how to handle temper tantrums? A) Distract the toddler with a toy when the toddler begins holding the breath B) Mimic the toddler's behavior by also holding the breath C) Promise the toddler a special activity if the toddler will stop D) Appear to ignore the toddler
D Temper tantrums are the natural result of frustration that toddlers have. Toddlers do not behave badly on purpose. They need time and maturity to learn the rules and regulations. During a temper tantrum, the advice is for the parent to ignore the behavior but ensure the toddler is safe. Rewarding temper tantrums can teach the toddler that tantrums are an effective method of interaction. Ignoring tantrums teaches the toddler that tantrums are ineffective. The parent needs to use self-control when dealing with a temper tantrum. This is a way to model acceptable behavior for the toddler. Page 1014
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: A) Initiative versus guilt B) Trust versus mistrust C) Industry versus inferiority D) Autonomy versus shame and doubt
D 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. Page 995
Which is the best way for parents to aid a toddler in achieving the developmental task? A) help the toddler learn to count B) urge the toddler to dress oneself completely alone C) give the toddler small household chores to do D) allow the toddler to make simple decisions
D The toddler years see a refinement of motor skills, continuous cognitive growth and the acquistion of language skills. During this time the toddler achieves autonomy and self-control. Allowing the child to make decisions is a good way to help the toddler achieve autonomy and gain independence. Rewarding the child for accomplishing the task after making the decision is a good way to reinforce self-esteem. A younger toddler may not achieve dressing alone because the toddler may not have mastered such techniques as buttons, zippers, or tying shoes. A toddler can help with household tasks but these are generally limited because the toddler's attention span and motor skills may not be refined enough to complete the task. Helping the child learn to count is improving cognitive development but does not necessarily help the child with gaining autonomy or self-control. Page 994
After teaching the mother of a 13-month boy old about suggestions for bathing and hygiene, the nurse determines that the teaching was successful when the mother states: A) "I'll drain the tub while he's still in it so he won't fall." B) "I'll wash his hair everyday with just plain soap." C) "I can use bubble baths to lure him into the tub." D) "It might be best to give him a bath in the evening."
D The young child's increased activity level necessitates bathing daily or every other day. A good time to bathe the child is after eating, either after breakfast or in the evening. Hair is washed two to three times per week with a mild shampoo. Bubble baths should be avoided, to prevent urethral irritation and possible development of cystitis. Some children may have fears associated with bathing such as being afraid of being sucked down the plug hole. In this case, do not drain the tub until the child is out of the room. Page 1010
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? A) Talks about a past event B) Uses two-word sentences or phrases C) Asks "why" often D) Half of speech understood by outsider
B 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. Page 998