Chapter 26: Growth and Development of the Toddler
The student nurse is preparing a presentation on normal physical growth for toddlers. What information should the student include? Select all that apply. a) Toddlers generally reach half of their adult height by 3 years of age. b) Head size becomes more proportional to the rest of the body near 3 years. c) The anterior fontanel (fontanelle) should be closed by the time the child is 24 months old. d) The average weight gain is 3 to 5 pounds per year. e) Toddlers gain height and weight in spurts.
Answers: B, D, E Explanation: The average toddler weight gain is 3 to 5 pounds per year. The anterior fontanel (fontanelle) should be closed by the time the child is 18 months old, not 24 months. Toddler gains in height and weight tend to occur in spurts, rather than in a linear fashion. Toddlers generally reach about half of their adult height by 2 years of age, not 3 years of age. Head size becomes more proportional to the rest of the body near the age of 3 years.
During a wellness care visit, the parents of a 2-year-old toddler report that they are struggling to deal with their toddler's daily and increasing number of tantrums. What information should be provided to the parents? Select all that apply. a) Ignoring the behavior is often helpful in reducing the duration of the tantrum. b) Maintaining a consistent daily routine can help to reduce tantrums. c) Tantrums at this age can signal the development of an aggression disorder in a toddler. d) Tantrums are a common occurrence for a toddler of this age. e) Tapping the toddler on the hands and voicing displeasure with the toddler's actions can successfully interrupt the behavior.
Answers: b, c, d Explanation: Temper tantrums can be a frequent occurrence in toddlers. Some toddlers are more prone to displaying these behaviors than others. For the toddler who experiences frequent tantrum outbursts, maintaining a consistent schedule for activities is helpful. Tantrum-prone toddlers benefit from a consistent nap, meal, and play periods. Ignoring the behavior signals to the toddler that the behavior is futile. Avoiding interaction with the toddler having the tantrum is beneficial.
The parent of a 20-month-old toddler reports the toddler has been becoming distraught when the parent leaves. The parent asks the nurse for advice about what is going on and how to best manage it. What information can be provided? Select all that apply. a) "As your toddler begins to learn that you will return, they will become less upset." b) "Your care providers may be frightening to your toddler." c) "This is actually a regression for your toddler because separation anxiety normally occurs in infancy." d) "This is a normal happening for a toddler of this age." e) "Establishing a routine for saying goodbye to your toddler will be helpful."
Answers: b, c, e Explanation: Separation anxiety occurs initially in infancy and then reoccurs again during the toddler stage. Separation anxiety for the toddler is normal. As the toddler begins to develop an understanding of object constancy, separation anxiety will ease. The toddler, while missing the parent, will begin to recognize that the parent will return. Establishing a routine for saying goodbye is helpful for the toddler. There is no indication that the care providers are problematic.
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 response by the nurse is best to facilitate a healthier diet? a) "Give him more healthy choices with less junk food available." b) "Calorie requirements for toddlers are less than infants." c) "You may have to serve a new food 10 or more times." d) "Serve only healthy foods. He'll eat when he's hungry."
a) "Give him more healthy choices with less junk food available." Explanation: Suggesting that the parents transition the child to a healthier diet by serving him more healthy choices along with smaller portions of junk food will reassure them that they are not starving their child. The parents would have less success with an abrupt change to healthy foods. Explaining calorie requirements and the timeline for acceptance of a new food does not offer a practical reason for making a change in diet.
What statement by the mother of a 20-month-old indicates a need for further teaching about nutrition? a) "New foods are offered along with ones she likes." b) "When she doesn't eat well at meals we give her nutritious snacks." c) "She drinks three 6-ounce cups of whole milk each day." d) "I give my daughter juice at breakfast and when she is thirsty during the day."
a) "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 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? a) "It is normal for children to engage in play alongside other children at this age." b) "Perhaps you should consider a preschool to promote more socialization opportunities." c) "Has your child displayed any aggressive tendencies toward other children?" d) "Does your child have opportunities to socialize much with other children?"
a) "It is normal for children to engage in play alongside other children at this age." Explanation: The social skills of the toddler at this age include parallel play. During parallel play children will play alongside each other rather than cooperatively. There is no indication that the aggression level of the child needs to be investigated. There is no indication the child needs increased socialization with other children.
The nurse is educating a parent regarding child safety for the 14-month-old toddler. What would the nurse include in the educational plan? a) Maintain supervision when the child is near stoves, ovens, irons and other hot items the child could reach. b) Utilize a front-facing car seat with appropriate harness straps until at least the age of 24 months. c) Assure there are no empty buckets in the home/play area that could result in accidental drowning. d) If the child reaches to touch a firearm, gently slap the child's hand and firmly state 'No.'
a) Maintain supervision when the child is near stoves, ovens, irons and other hot items the child could reach. Explanation: Toddlers are more mobile and curious, leading to accidental burns on stoves, ovens, irons etc. They must be supervised when near these objects to avoid burns. If firearms are in the home, they should be unloaded and locked in a secure location. Educating the toddler about firearm safety will not be remembered and is appropriate for a much older child. Buckets are a danger to toddlers (who are top heavy) if they have water in them and could result in a drowning. Empty buckets are not a drowning concern. Children are to be placed in a rear-facing car seat until 2 years of age, not a front-facing one.
The 18-month-old toddler has most likely attained which gross motor skill? a) The ability to walk independently. b) The ability to balance on one foot. c) The ability to walk up stairs alone. d) The ability to pedal a tricycle.
a) 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 providing education to a parent about their 20-month-old child's growth. The parent states that their child seems to have such a big head. What information should the nurse include in the response? a) The heads of children at this age are large in proportion to the rest of their body. b) The child looks normal. c) Some children have large heads but that does not signal a problem. d) The appearance of the head being larger than the body will remain until the child is about 6 years old.
a) The heads of children at this age are large in proportion to the rest of their body. Explanation: Head circumference increases about 1 in (2.5 cm) between 1 and 2 years of age, then increases an average of 0.5 in (1.25 cm) per year until age 5. By 2 years of age, the child's head circumference is approximately 85% of their expected adult head circumference.
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) exploring one's body b) playing on the picnic table c) choosing one's own foods d) deciding one's bedtime schedule
a) exploring one's body Explanation: 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.
A 2-year-old toddler holds his breath until passing out when he wants something the parent does not want him to have. The nurse would decide whether these temper tantrums are a form of seizure based on the fact that: a) seizures are not provoked; temper tantrums are. b) with seizures, cyanosis rarely develops. c) seizures typically occur with fever; temper tantrums do not. d) seizures rarely occur in toddlers.
a) seizures are not provoked; temper tantrums are. Explanation: 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.
The nurse is assessing the language development of a 3-year-old girl. Which finding would suggest a problem? a) makes simple conversation b) speaks in 2- to 3-word sentences c) tells the nurse her name d) tells the nurse she saw Na-Na today
b) speaks in 2- to 3-word sentences Explanation: If the child is still speaking telegraphically in only 2- to 3-word sentences, it suggests there is a language development problem. If the child makes simple conversation, tells about something that happened in the past, or tells the nurse her name she is meeting developmental milestones for language.
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? a) "He wasn't bothered by the paint smell." b) "He doesn't respond if I wave to him." c) "He was licking the dishwashing soap." d) "I dropped a pan behind him and he cried."
b) "He doesn't respond if I wave to him." Explanation: The fact that the child does not respond when the mother waves to him suggests he may have a vision problem. The toddler's sense of smell is still developing, so he may not be affected by odors. Their sense of taste is not well developed either, and this allows him to eat or drink poisons without concern. The child's crying at a sudden noise assures the nurse that his hearing is adequate.
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) "When my toddler falls down, they always wants me to pick them up." b) "My toddler uses the potty chair and is dry all day long." c) "My toddler has temper tantrums when we go to the store." d) "Every night my toddler follows the same routine at bedtime."
b) "My toddler uses the potty chair and is dry all day long." Explanation: 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.
The nurse is caring for an 18-month-old child. The nurse is aware that the child is which stage according to Erikson? a) Trust versus mistrust b) Autonomy versus shame and doubt c) Initiative versus guilt d) Industry versus inferiority
b) Autonomy versus shame and doubt Explanation: Erikson defines the toddler period as a time of autonomy versus shame and doubt. Erikson defines Initiative versus guilt as the preschool period. Erikson defines trust versus mistrust as the infancy period and industry versus inferiority as the school age period.
The nurse is observing a 3-year-old boy in a day care center. Which behavior might suggest an emotional problem? a) sucks his thumb periodically b) has persistent separation anxiety c) goes from calm to tantrum suddenly d) is unable to share toys with others
b) has persistent separation anxiety Explanation: 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.
A mother is concerned because her 14-month-old son, who had a big appetite when breastfeeding a few months ago, seems uninterested in eating solid food. She still breastfeeds 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 not normal for toddlers to lose their appetites; have him tested for a gastrointestinal condition." c) "It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate." d) "It is not normal for toddlers to lose their appetites; spoon feed him yourself to make sure he gets proper nutrition."
c) "It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate." Explanation: 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 that 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.
The nurse is discussing language development with the parent of a 20-month-old toddler. To accurately assess the toddler's language development, which question would the nurse ask the parent? a) "Is your toddler able to use singular and plural words correctly?" b) "Can your toddler state his or her name and indicate his or her age?" c) "When you say "no" does your toddler seem to understand the meaning?" d) "Does your toddler use sentences with 3 or 4 words?"
c) "When you say "no" does your toddler seem to understand the meaning?" Explanation: The 20-month-old toddler should understand the word "no." Being able to use plurals, using 3 to 4 word sentences, and stating one's name and age are expectations of a child 36 months of age or older.
A 3-year-old child is hospitalized. The parents are concerned because the child is now refusing to use the potty and is wetting the bed even though the child has achieved toilet training. Which response by the nurse is most appropriate? a) "Why do you believe your child is refusing to use the potty?" b) "Once discharged, your child will quickly learn to use the toilet again." c) "Your child is experiencing regression as a result of stress." d) "Do not worry. This is a normal response to being in the hospital."
c) "Your child is experiencing regression as a result of stress." Explanation: Regression is a change from present behaviors to past developmental levels of behavior. This is a normal response among children during times of intense stress, such as a hospitalization or the birth of a new sibling. The nurse should not tell the parents not to worry. The child will not have to learn to use the toilet again. The behavior is already learned. Asking why is not a therapeutic form of communication and may cause the parents to become unnecessarily defensive.
The nurse is assessing a toddler's fine motor skills. Which finding by the nurse could be a safety concern? a) Put shapes into matching openings b) Ability to hold a crayon to write c) Ability to turn door knobs d) Able to use a spoon to self-feed
c) 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.
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) Promise the toddler a special activity if the toddler will stop c) Appear to ignore the toddler d) Mimic the toddler's behavior by also holding the breath
c) Appear to ignore the toddler Explanation: 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.
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? a) Determine when this form of play was first noted. b) Document the finding in the medical records. c) Explain that this is normal behavior for toddlers. d) Encourage the toddlers to play to allow for observation.
c) 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.
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) Tried to refocus the child's attention as tantrum behavioral cues appeared c) Reasoned with the child to stop the behavior d) Remained relatively calm even though embarrassed
c) 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.
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 demonstrates separation anxiety. Explanation: 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.
The home health nurse is visiting a 2-year-old client's home. Which finding will cause the nurse to intervene? a) The toddler goes to the bathroom alone to urinate. b) The toddler in not allowed in the kitchen while food is being prepared. c) The family's medications are located in a kitchen drawer. d) All of the windows in the home are locked.
c) The family's medications are located in a kitchen drawer. Explanation: Poisoning is at peak incidence during the toddler period. Special precautions need to be taken against poisoning at this time. This includes keeping all medications in a high, locked cabinet. It is appropriate for all windows to be locked to prevent a toddler from exiting the home out a window. The toddler may go to the bathroom alone once toilet training is well established. Not allowing the toddler in the kitchen during meal preparation will prevent accidental burns from hot foods and surfaces.
A toddler's parent reports that their child will only eat peanut butter and jelly sandwiches for several days in a row. The child will then refuse to eat these sandwiches for several weeks. How should the nurse best document this behavior? a) echolalia b) egocentrism c) food jag d) physiologic anorexia
c) food jag Explanation: During a food jag, the toddler may prefer only one particular food for several days, then not want it for weeks. Physiologic anorexia describes the fact that toddlers do not require as much food intake for their size as they did in infancy. Echolalia is repetition of words and phrases. Egocentrism describes the focus on oneself that is present in toddlers.
During a visit to the pediatric clinic the mother of a 2-year-old tells the nurse that her husband is concerned that their son isn't potty trained yet. The mother states, "There is no way he could be potty trained. His bladder is too small." How should the nurse respond? a) "Your husband is correct, at the age of 2 your son should have a good amount of urine control." b) "Two years old is rather early for a boy to be potty-trained." c) "You should talk to the physician about your son not being potty-trained in case there are issues preventing him from being able to control his urine flow." d) "The bladder of a 2-year-old is actually the size of an adult's bladder, but there are a lot of variables to when a child is potty-trained."
d) "The bladder of a 2-year-old is actually the size of an adult's bladder, but there are a lot of variables to when a child is potty-trained." Explanation: Bladder and kidney function reach adult levels by 16 to 24 months of age, but there are many factors that determine when a child is ready to be potty-trained. The other options are misleading the parent regarding potty-training.
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) "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." b) "The best time to start toilet training is as soon as the child begins walking." c) "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." d) "When she starts tugging on a wet or dirty diaper, she is letting you know she's ready."
d) "When she starts tugging on a wet or dirty diaper, she is letting you know she's ready." 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. 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.
Which is the best way for parents to aid a toddler in achieving the developmental task? a) Give the toddler small household chores to do b) Help the toddler learn to count c) Urge the toddler to dress oneself completely alone d) Allow the toddler to make simple decisions
d) Allow the toddler to make simple decisions Explanation: The toddler years see a refinement of motor skills, continuous cognitive growth, and the acquisition 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 successfully dress alone because he or she 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.
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? a) Excess fluid volume related to inability to control urination b) Total urinary incontinence related to delayed toilet training c) Ineffective coping related to lack of self-control of 2-year-old toddler d) Deficient parental knowledge related to inappropriate method for toilet training
d) 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.
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 be able to count out loud to 20. b) The toddler should say 20 nouns and 4 pronouns. c) The toddler should say two words plus "ma-ma" and "da-da." d) The toddler should speak in two-word sentences ("Me go").
d) 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.
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? a) Half of speech understood by outsider b) Talks about a past event c) Asks "why" often d) Uses two-word sentences or phrases
d) 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.
