PrepUs for Pediatrics Chapter 25

The caregiver of a 6-year-old expresses concern that the child cannot yet print the first and last name. The caregiver is wondering if this is normal. Which response by the nurse would be most appropriate?

"By the age of 6, most children can print some letters and maybe their first name." By 3 years of age, a child should be able to hold a pencil in the writing position. By age 4, the child can draw circles and squares and a body with four parts. At age 5, the child can print letters, copy a triangle and a pictue of a person with six parts and cut with scissors. The 6-year-old child can print letters or numbers and may be able to print his or her own name. Children do not write in cursive until school age.

The nurse is caring for a 3-year-old at a well child check. The parent states that her child still has an afternoon nap but she has a friend whose toddler no longer naps in the afternoon. She is seeking advice on what do to. When providing anticipatory guidance to the parent about sleep patterns, what is the most appropriate response by the nurse?

"Often, the afternoon nap will be no longer needed after 4 years." Exact duration of a child's daily sleep patterns varies based on temperament, activity levels, and overall health. Around the age of 4, many children discontinue the afternoon nap.

A 3 1/2 year-old child is found masturbating in the family living room. Which response by the parent would best address this behavior?

"We do not touch ourselves in public. Please go to your room if you want to continue this behavior." Although masturbation in this age group is not an uncommon behavior, the child must be told in a matter-of-fact manner that this is not appropriate activity in public. The parent needs to remain calm and not get angry or embarrassed. Usually, masturbation is just part of a young child's curiosity about his or her body.

The parent of a four year-old child has expressed concern that the child is wetting her bed several times each week. What should the nurse teach the parent?

Bed wetting is not an unexpected behavior at this age Bed wetting is not normally considered a problem unless it persists after the ages of 5 to 7. Limiting fluids after midafternoon may create a risk for dehydration.

The nurse is providing anticipatory guidance for parents of a preschooler regarding sex education. What is a recommended guideline when dealing with this issue?

Before answering questions, find out what the child thinks about the subject. Preschoolers are very inquisitive and want to learn about everything around them; therefore, they are very likely to ask questions about sex and where babies come from. Before attempting to answer questions, parents should try to find out first what the child is really asking and what the child already thinks about that subject. Then they should provide a simple, direct, and honest answer. The child needs only the information that he or she is requesting.

The parents of a 4-year-old who is a picky eater ask the nurse what foods to include in their child's diet to provide adequate iron consumption. Which food would the nurse recommend?

Cooked lentils Lentils are a good source of iron. Whole milk, oranges, and sweet potatoes are good sources of calcium.

Which immunization would you plan to administer at a preschool health maintenance visit?

DTaP Preschoolers are typically administered a booster or their fourth dose of DTaP vaccine prior to starting school.

The nurse is caring for a 5-year-old girl post-tonsillectomy. The girl looks out the window and tells the nurse that it is raining and says, "The sky is crying because it is sad that my throat hurts." The nurse understands that the girl is demonstrating which mental process?

Magical thinking The nurse understands that the girl is demonstrating magical thinking. Magical thinking is a normal part of preschool development. The preschool-age child believes her thoughts to be all-powerful. Transduction is reasoning by viewing one situation as the basis for another situation whether or not they are truly causally linked. Animism is attributing life-like qualities to inanimate objects. Centration is focusing on one aspect of a situation while neglecting others.

A preschool-age child tells the nurse about an imaginary friend. The parents are concerned because the child refuses to do anything without the friend's help. Which nursing diagnosis is most applicable for the family?

Parental anxiety related to lack of understanding of childhood development The parents need to understand that the child's behavior is not uncommon. Imaginary friends are common in the preschool-age child. The child's behavior is not abnormal. The child does not have a deep-set psychological need. The child is not at risk for social isolation.

The nurse is teaching the preschooler's parents injury prevention. Which method would the nurse advise for the parents as the best way to enforce injury prevention?

Repetition and reinforcement Injury prevention involves adults actively searching the indoor and outdoor environment of the home and other areas where the child may frequently spend time. This keeps the environment "explorable," prevents conflicts, and enables the child to expand on skills that need mastering. Safety rules and constant vigilance are only a small part of enforcing injury prevention.

The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?

"Tell me about the circumstances when this occurs." Bladder control is present in 4- and 5-year-olds, but an occasional accident may occur, particularly in stressful situations or when the child is absorbed in an interesting activity. The nurse needs to ask an open-ended question to determine the circumstances when the child has had accidents. Simply telling the mother that it is normal does not address the mother's concerns. The nurse does need to gather more information, because accidents in a previously potty-trained child can be a sign of diabetes.

A 5-year-old girl is pretending to be a crocodile during a physical examination. Her mother just smiles and rolls her eyes at the nurse. What would be the best response for the nurse to give the child?

"What a wonderful imagination you have! I've never seen anyone who was so good at pretending to be a crocodile." Parents sometimes strengthen a fantasy role without realizing it. A preschooler might be pretending she is a crocodile. If the nurse plays along, the child may be frightened she has actually become a crocodile. A better response is to support the imitation—this is age-appropriate behavior and a good way of exploring roles—by saying, "What a nice crocodile you're pretending to be." This both supports the fantasy and reassures the child she is still herself.

The nurse is speaking with the parent of a 4-year-old child. Which statement by the parent would suggest a need for further investigation?

"When we go to the park, my child never wants to play with the other children." Preschool aged children start to play together. This is defined as cooperative play. Imaginative play such as dress-up, role play and utilizing toys/objects for other purposes other than they were intended is common in this age.

The nurse is conducting a well-child examination of a 5-year-old girl, who was 40 inches tall at her last examination at age 4. Which height measurement would be within the normal range of growth expected for a preschooler?

43 inches

A nurse is caring for a 4-year-old child that will be undergoing a procedure to remove a mass from the abdomen. In order to help the child remain calm in preparation for getting an IV catheter placed, what intervention might the nurse implement?

Allow the child to play with a procedure doll. The nurse can allow the child to play with a procedure doll that will simulate the procedure for the child.

The mother of a preschooler finds a broken plate in her kitchen floor and asks the child what happened. The child tells the mother that her imaginary friend Lulu dropped it when she was getting it out of the cabinet. How should the mother interpret this fabrication?

Blaming an imaginary friend for accidents is normal behavior for this age group. Children this age often have imaginary friends to play with and may blame the friend for accidents or other occurrences in the home that they may have caused. This should not be interpreted as intentionally lying or abnormal but rather normal preschool behavior.

A 5-year-old child is overheard by her parents calling her dog a "fat boo-boo butt" and they are concerned. What advice would the nurse provide for them regarding this behavior?

Calmly correct the child, telling her not to say those words again. Children this age often try out naughty words to see what kind of reaction they will get from their parents. Parents are encouraged to express their disapproval with the language and calmly tell the child not to say those words again. Ignoring the behavior will not correct it and punishment is not necessary.

A parnt tells the nurse about being frustrated because the preschooler screams every time that parent attempts to buckle the child's seat belt. What advice should the nurse give this parent?

Do not start the car until seat belts are in place Accident prevention is important for preschoolers. It can best be taught by role modeling. Not starting the car until everyone is buckled up is an example. Bribing and threatening are not appropriate, nor is keeping the child home at all times. All children up to 4 years whose height meets car seat requirements should be in a forward facing approved car seat with harness and top tether. After reaching the height requirements the child can transition to a booster seat with lap and shoulder belts.

The nurse is caring for a preschool-aged child who needs a CT scan. Which action would the nurse use to best prepare the child for this diagnostic test?

Help the child to pretend that the CT scan machine is a camera. Because preschoolers' imagination is so active, this leads to several fears such as fear of the dark and mutilation. The nurse needs to help the child understand that the CT scanner is like a camera to take pictures of the body parts. Threatening the child to follow directions or becoming hurt plays into the child's fear of mutilation. Telling the child to behave creates a fear of punishment. Telling the child that the CT scan is a picture of the body's dark parts plays into the child's fear of the dark.

A nurse is describing growth and development during the preschool period. What would the nurse identify as a predominant and heightened characteristic for this age group?

Imagination Although vocabulary, gross motor skills, and fine motor skills improve during this time, the imagination of preschoolers is keener than it will be at any other time in their lives. They imitate behavior that they see exactly.

A father and his 4-year-old son are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the boy doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

Opening drawers in the room, pulling out supplies, and examining them The developmental task for the preschool-age child is to achieve a sense of initiative versus guilt (Erikson, 1993). Children with a well-developed sense of initiative like to explore as they have discovered that learning new things is fun. Opening the drawers, pulling out supplies, and examining them is the best example of initiation and exploration among these answers. Rough-housing and singing a song learned in preschool are examples of typical play for preschool children. Reading a book at age four would be developmentally precocious but would not necessarily be the best example of initiative.

Fear of mutilation is significant during the preschool age.

True Fear of mutilation is significant during the preschool age, as revealed by the intense reaction of a preschooler to even a simple injury such as falling and scraping a knee or having a needle inserted for an immunization. A child cries afterward not only from the pain but also from the intrusiveness of the injury or procedure.

A parent of a 4-year-old preschooler asks the nurse about how to discipline her child for bad behavior. The nurse would recommend that the parent take which steps to discipline the child? Select all that apply.

Set consistent limits and adhere to them. Take away the child's favorite toy until behavior improves. Attend only to the good behavior—ignore acting out Preschoolers require consistency in discipline and limit-setting. Although each family determines their limits, children need limits that are the same every time. Discipline for preschoolers also includes time out for one minute per year of age, ignoring negative behavior, and praising good behavior. Additionally, taking away a toy or activity that the child loves can be an effective form of discipline. Physical punishment removes the responsibility of correct behavior from the child and expresses anger by the parent.

Which gross motor skill would the 4-year-old child have most recently attained?

The child can hop on one foot Gross and fine motor skills continue to develop rapidly in the preschool-age child. Gross motor skills have to do with the development of large muscles. Balance improves and around the age of 4, thus the child can hop on one foot and stand on one foot for 5 seconds. A 3-year-old child does not have the ability to accomplish these tasks. A 5-year-old child can button his/her own clothes, tie their shoes, and cut his/her food.

The nurse is supervising lunch time for children on a pediatric ward. Which observation is considered abnormal for this age group?

The child uses his fingers and refuses to use a fork. The preschool child has learned to use utensils fairly effectively to feed himself or herself, has a full set of primary teeth, and is able to chew and swallow competently. Preschool children may be picky eaters. They may eat only a limited variety of foods or foods prepared in certain ways and may not be very willing to try new things.

The nurse is caring for a premature baby in the NICU. The mother reports that the infant's normally happy and outgoing 5-year-old sister is acting sad and withdrawn. The nurse understands that due to her developmental stage, the girl is at risk of what happening?

Viewing her baby sister's illness as her fault Since the preschool child is facing the psychosocial task of initiative versus guilt, it is natural for the child to experience guilt when something goes wrong. The child may have a strong belief that if someone is ill or dying, he or she may be at fault and the illness or death is punishment. It is less likely that the girl would be at risk of harming the baby or experiencing clinical depression as a result of the baby's illness. The child may create an imaginary friend to cope with the illness, but would not withdraw or express sadness as a result of the imaginary friend.

A nurse is providing an anticipatory guidance class on safety for parents of preschoolers. Which interventions are important for the nurse to address during the class? Select all that apply.

bicycle safety stranger awareness swimming lessons It is in the preschool years that children often begin to feel comfortable in water. It is important for parents to teach beginning swimming to reduce the risk for accidental drowning. Parents should teach preschoolers that not all people are friends and to be aware of anyone that the child does not know. Bicycle safety is important at a young age and includes helmet safety and crossing streets.

Parents of a 3½-year-old indicate they spend time with grandparents who live near a lake. The nurse will emphasize:

having the child wear a personal flotation device whenever near or on the water. Preschool children are safe around water only when adult supervision is constant. Wearing a personal flotation device adds additional protection and should be as routine as "buckling up" in the car. At 5 years old, most preschoolers are mature enough to become swimmers; yet knowing how to swim does not make the preschooler safe without supervision. CPR is a life-saving skill and using sunscreen will protect the skin, but neither will be a factor in preventing drowning.

When planning how to respond to a 3-year-old child about telling stories ("tall tales"), the nurse would base the statement on the fact that:

imagination in a 3-year-old is at its peak. Preschoolers have vivid imaginations and love to play "make believe." They are inquisitive learners. It is not unusual for their imaginations to create "tall tales" and be in a world of make-believe. Preschoolers have a vocabulary of between 1,500 and 2,100 words, depending upon their age. They can count to 10 and know at least 4 colors. Their comminication is concrete. At this age they are not capable of abstract thought. During the preschool years, the child develops a sense of identity. They know who they are and to the family in which they belong. They develop the knowledge of right and wrong. The preschool years help develop the child's sense of belonging and their place in the world.

The most important safety precaution for parents to teach preschoolers is:

not to ride in a car with strangers Preschoolers begin to spend more time away from parents than formerly as they begin preschool. That makes it a time to learn about people and traffic safety

When assessing the growth and development of a 4-year-old, which would the nurse note as being appropriate?

tells a fantasy story about a bear and a car The nurse should recognize that by age 4, the preschooler should have a vocabulary of about 1,400 words. Preschoolers are able to communicate in sentences of five words or more and often like to use their imagination. This is a normal part of growth and development and should be encouraged.

The nurse is discussing nutritional issues and concerns with the caregivers of preschoolers. Which statement made by the caregivers best indicates a common aspect of the diet and nutrition of the preschool child?

"My child is so picky and eats the same thing every day for days on end!" The preschooler's appetite is erratic. At one sitting the preschooler may devour everything on the plate, and at the next meal he or she may be satisfied with just a few bites. Food jags, such as eating the same thing for days on end, are common in the toddler, not the preschooler. Preschooler's are picky eaters. They may eat only a limited variety of foods or foods prepared in only one way. Portions for preschoolers are smaller than adult-sized portions, so the child may need to have meals supplemented with nutritious snacks. Giving the child non-nutritious snacks may cause the child not to eat at mealtimes. The child eating as much as the adolescent sibling is being set up for obesity.

If the child is gaining weight at an expected rate, a child who weighs 36 lb (16.3 kg) at 3 years of age would weigh what amount at age 5?

44 to 46 lb (20 to 21 kg) The preschool age child gains about 4 to 5 lb (1.8 to 2.3 kg) each year and grows about 2.5 to 3 in (6.3 to 7.6 cm). So a 36 lb (16.3 kg) child at 3 years gaining 4 to 5 lb (1.8 to 2.3 kg) per year would be 44 to 46 lb (36 lb + 8 lb = 44 lb; 36 lb + 10 lb = 46 lb).

What would be most effective in helping promote initiative and nutritional health for a preschooler?

Allowing the child to spread soft cheese on crackers

Parents say they have been using measures to lessen the struggle of getting their preschooler to bed at night and to sleep. Which practice will the nurse suggest they discontinue?

Allowing the preschooler to fall asleep wherever and whenever the child is tired enough Consistent bedtimes and places for sleep promote good sleep habits. Caffeine (soft drinks) interferes with sleep. A nightlight can reduce fear of the dark common in preschoolers. Removing the TV from the child's room prevents viewing and screen light from keeping her awake. Twelve hours of sleep daily is an average amount for preschoolers

During the preschool years, female children may develop a strong attachment to their fathers. What is this attachment called?

Electra complex Freud stressed that girls experience a deep attachment to their father during the preschool years (Electra complex) similar to an Oedipus complex in boys.

Parents ask for disciplinary guidance for their 4-year-old. The nurse suggests which of these actions? Select all that apply.

Anticipate situations likely to cause misbehavior and redirect the child to another activity. When discussing improper behavior, call the behavior "bad" or "naughty," not the child. Books and stories can help preschoolers master proper behavior. Spanking is the least effective discipline and discouraged by pediatric professionals. If chosen by parents, it should be infrequent and done only with an open hand. Labeling behavior and not the child supports self-esteem. One minute per year of age is an appropriate length for time-outs. Redirecting from events that tend to lead to misbehavior is wise and reduces conflict. Preschoolers can learn much from stories and books including appropriate behavior.

The nurse is watching a 4-year-old child play with another preschool child. The children are playing a game with rules. The nurse notes that the child is demonstrating what type of play?

Cooperative play Cooperative play is when children play in a group with each other, and play by rules. Examples are board games or sports. Associative play involves allowing the child to work through feelings about procedures and separation; parallel play involves children playing side to side with each engaging in his/her own activities; dramatic play involves living out of the drama of human life.

The nurse is organizing an indoor play area for preschoolers. What play materials are least important?

Electronic teaching toys These are expensive and usually cannot be used in multiple ways or shared with a group of children. All the rest of the items have many uses, stimulate imagination and creativity, promote social interaction, and are relatively inexpensive and readily replaced.

Which type of play should the nurse encourage for a preschool-age child who is hospitalized?

Dressing in the mother's coat to play house Preschool-aged children have active imaginations and dressing up to play house would be an appropriate play activity for the nurse to encourage. The child's fine motor skills are not developed to play an electronic handheld game. Children of this age are afraid of the dark so turning out the lights to play hide and seek is not appropriate. Planting flower bulbs is an activity that is too long-term for this age range.

The nurse is providing health-promotion teaching to a group of parents of preschoolers at a local daycare. What information would the nurse include in this education session? Select all that apply.

Encourage children to select their own clothing to wear each day. Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing. Parents will need to supervise tooth-brushing and be responsible for flossing. Preschoolers are becoming more independent and need to be allowed to pick out their own clothing, brush their teeth with adult supervision, and take care of their own toileting. If the child has an accident, treat it in a matter-of-fact manner and do not make a big deal out of it. Helmets are worn every time the child rides a bicycle, regardless of distance.

A nurse is observing a 3-year-old preschooler engaged in play. What behavior would the nurse most likely expect to observe?

Imitative play Preschoolers enjoy games that use imitation such as pretending to be teachers, cowboys, firefighters, and store clerks. They imitate exactly what they see their parents doing. Parallel play is characteristic of toddlers. Preschoolers are capable of sharing and play with other children as a means for socialization. Older preschoolers are interested in group games.

The nurse is counseling parents of a picky eater on how to promote healthy eating habits in their child. Which intervention would be appropriate advice?

Present the food matter-of-factly and allow the child to choose what to eat. The parents should maintain a matter-of-fact approach, offer the meal or snack, and then allow the child to decide how much of the food, if any, he or she is going to eat. High-fat, nutrient-poor snacks should not be substituted for healthy foods just to coax the child to "eat something." If the preschooler is growing well, then the pickiness is not a cause for concern. A larger concern may be the negative relationship that can develop between the parent and child relating to mealtime. The more the parent coaxes, cajoles, bribes, and threatens, the less likely the child is to try new foods or even eat the ones he or she likes that are served. The child should be offered a healthy diet, with foods from all groups over the course of the day as recommended by the U.S. Department of Agriculture.

The developmental task of preschoolers is to achieve a sense of:

initiative versus guilt. Developing a sense of initiative, or learning how to do things, is the developmental task of the preschool period. In this stage the child is developing a conscious and is able to determine right from wrong. This age child is an inquisitive learner and is enthusiastic about learning. Erickon's stage of autonomy versus shame and doubt is the developmental tasks of toddlers from 1 to 3 years old. The other stages listed are not correct Erickson stages or developmental tasks.

The parents of a preschooler express concern to the nurse about their son's new habit of masturbating. What is an appropriate response to this concern?

Treat the action in a matter-of-fact manner, emphasizing safety. Masturbation is a healthy and natural part of normal preschool development if it occurs in moderation. If the parent overreacts to this behavior, then it may occur more frequently. Masturbation should be treated in a matter-of-fact way by the parent. The child needs to learn certain rules about this activity: nudity and masturbation are not acceptable in public. The child should also be taught safety: no other person can touch the private parts unless it is the parent, doctor, or nurse checking to see when something is wrong.

A nurse walks into the room to check on a preschool client. When the nurse asks the preschooler how she is doing, the child says she is Tinker Bell. What is the best response by the nurse?

"That will be fun if you want to pretend you are Tinker Bell!" Preschoolers engage in fantasies as part of their development. The nurse, however, needs to support the imitation but at the same time help the child to maintain the difference between pretend and real. The best response by the nurse would be to tell the client it will be fun to pretend she is Tinker Bell. Trying to call the child by the real name when the child is in imaginary play is very confusing to the child.

The parents of a 4-year-old ask the nurse when their child will be able to differentiate right from wrong and develop morals. What would be the best response of the nurse?

"The preschooler is developing a conscience." The preschool child can understand the concepts of right and wrong and is developing a conscience. Preschool children see morality as external to themselves; they defer to power (that of the adult). The child's moral standards are those of their parents or other adults who influence them, not necessarily their own.

A parent brings her 3-year-old child in for a sick visit for the third time this year. The child, who attends a preschool program, continues to develop upper respiratory infections. The parent is frustrated with the situation and asks the nurse for advice. What would be the best recommendation for the nurse to give to the parent in this situation?

Make sure that frequent handwashing is being stressed at the preschool Even though the number of major illnesses is few in this age group, the number of minor illnesses, such as common colds and ear infections are high. Children who attend childcare or preschool programs have an increased incidence of gastrointestinal disturbances (vomiting and diarrhea) and upper respiratory infections from the exposure to other children unless frequent handwashing is stressed at the setting. Withdrawing the child from preschool likely is not a viable option for the parent. Sending the child to preschool with a healthy snack, although a good recommendation, will not help prevent upper respiratory infections. Teaching the child to cover the mouth when sneezing is helpful in preventing transmission of infections to other children but not in preventing the child from becoming infected.

The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?

Reward the child for initiative in order to build self-esteem. The building of self-esteem continues throughout the preschool period. It is of particular importance during these years, as the preschooler's developmental task is focused on the development of initiative rather than guilt. A sense of guilt will contribute to low self-esteem, whereas a child who is rewarded for his or her initiative will have increased self-confidence. Routine and ritual continue to be important throughout the preschool years, as they help the child to develop a sense of time as well as provide the structure for the child to feel safe and secure. Also, consistent limits provide the preschooler with expectation and guidance. Giving children opportunities to decide how and with whom they want to play also helps them develop initiative.