Chapter 26: Growth and Development of a Toddler

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." Rationale: 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?

"It is normal for children to engage in play alongside other children at this age." Rationale: 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.

A mother of a toddler asks the nurse, "How will I know that my daughter is ready for toilet training?" Which response by the nurse would be most appropriate?

"You'll probably notice that your daughter is uncomfortable in wet diapers." Rationale: The markers of readiness for toilet training are subtle, but as a rule, children are ready for toilet training when they begin to be uncomfortable in wet diapers. Although the rectal and urethral sphincters are mature by the end of the first year, children are not cognitively and socially ready. In fact, many children do not understand what is being asked of them until they are 2 or even 3 years old.

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.

-"This is a normal happening for a toddler of this age." -"Establishing a routine for saying goodbye to your toddler will be helpful." -"As your toddler begins to learn that you will return the toddler will become less upset." Rationale: 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.

Which is the best way for parents to aid a toddler in achieving the developmental task?

Allow the toddler to make simple decisions Rationale: 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?

Deficient parental knowledge related to inappropriate method for toilet training Rationale: 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.

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 Rationale: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?

The child demonstrates separation anxiety. Rationale: 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.

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"). Rationale: 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.

A parent is concerned because the toddler refuses to share. What is the nurse's best response to the parent regarding this concern?

This is normal toddler behavior; sharing is learned later. Rationale: Play is the major socializing medium for the toddler. Toddlers exhibit parallel play instead of cooperative play. Sharing is not usually learned until the preschool period. Because toddlers have such short attention spans, they change toys and activities frequently. This also is not conducive to sharing. Because parallel play is normal for the toddler, the parent should be assured the toddler is developing normally and no restrictions are needed.

The nurse is explaining safety precautions for toddlers to the mother of a normal 30-month-old boy. Which activity might the nurse suggest may be done without supervision?

Undressing himself Rationale: The child would be capable of safely dressing or undressing himself with some success. Turning on the bath water, playing in the basement, or eating a mid-afternoon snack could present significant risk for injury if not supervised.

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

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

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

frequently babbles to herself when playing Rationale: The nurse would be concerned if the child is babbling to herself rather than using real words. By this age, she should be using simple sentences with a vocabulary of 50 words. Being unwilling to share toys, playing parallel with other children, and moving to different toys frequently are typical toddler behaviors.

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

has persistent separation anxiety Rationale: 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 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:

seizures are not provoked; temper tantrums are. Rationale: 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.

A 3-year-old child is seen at the clinic for a checkup. When collecting information, the child's parent reports concern about the child's stools because sometimes the child passes what appears to be undigested food. What response by the nurse is appropriate?

"At this age, the digestive tract is not completely mature and children may pass undigested food." Rationale: The digestive systems of 3-year-old children are not fully mature and they may sometimes pass pieces of undigested food. This is a normal occurrence. The reason for this occurrence should be explained to the child's parent. When the nurse asks the parent "Why," this is demonstrating poor therapeutic communication skills and will cause the parent to become defensive. The symptoms of pain or straining would be indicative of constipation, not passing undigested food. There is no indication that the diet being ingested is not appropriate.

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?

"Give him more healthy choices with less junk food available." Rationale: 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.

The parent of a toddler notices the child plays nicely next to another toddler but does not play with that child. The parent expresses concern about this behavior to the nurse during an examination. Which response by the nurse is appropriate?

"This is called parallel play and is normal for this age group." Rationale: Typical play of the toddler period is beside, not with, another toddler (parallel play). No further assessment is needed, nor does this indicate an autism spectrum disorder. The nurse should respond to the parent and not simply tell the parent to talk to the primary health care provider as this does not address the parent's concern.

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?

"Your child is experiencing regression as a result of stress." Rationale: 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.

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.

-The nurse/mother notes that the toddler's car seat is located in the passenger front seat. -The parent is busy entertaining guests and did not notice the toddler running out in the neighborhood street to get a toy. -The parents allow the toddler to climb up on the counter and watch as food is stirred on the stove. Rationale: 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 30-month-old toddler have brought the toddler into the emergency department because of a seizure. During the health history, the nurse learns that the toddler was frustrated and angry immediately preceding the seizure. The nurse suspects the toddler had a breath-holding spell. Which parental report suggests breath-holding?

A tantrum preceded the event. Rationale: 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.

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 Rationale: 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?

Appear to ignore the toddler Rationale: 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 the language development of a 3-year-old girl. Which finding would suggest a problem?

speaks in 2- to 3-word sentences Rationale: 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.