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A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?

Falls when throwing a ball overhand

Goes up stairs with two feet on each step

Runs with a wide stance

Refers to self by name

Answer and Explanation

The Correct Answer is D

A. It is expected for a 24-month-old to have some difficulty with coordination when throwing a ball.

B. Using both feet on each step when going upstairs is developmentally appropriate at this age.

C. Running with a wide stance is common in toddlers as they develop balance and coordination.

D. This is the correct answer. By 24 months, a toddler should begin using pronouns such as "I" or "me" instead of referring to themselves by name, indicating a possible language delay.

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Correct Answer is A

Explanation

A. "I'll place him in the back seat facing the back seat." – This is the correct answer. Infants should always ride in a rear-facing car seat in the back seat until at least 2 years of age.

B. "I'll place him in the front seat facing the front of the car." – The front seat is not safe for infants due to airbag deployment risks.

C. "I’ll place him in the back seat facing the back of the front seat." – This wording is unclear, but the safest position is directly facing the back of the car.

D. "I’ll place him in the front seat facing the back of the car.” – Infants should not be placed in the front seat, even if rear-facing.

A. Empty the collection chamber every 8 hr. B. Check the patency of the tubing every 2 hr. C. Keep the drainage system above the level of the client's chest. D. Ensure 2 cm (0.8 in) of water is in the water seal chamber.

Correct Answer is D

Explanation

A. Empty the collection chamber every 8 hr – Incorrect. The collection chamber is not emptied; instead, it is replaced when full to prevent air re-entry.

B. Check the patency of the tubing every 2 hr – While monitoring the tubing is essential, checking patency is not the most specific nursing priority.

C. Keep the drainage system above the level of the client's chest – Incorrect. The system should remain below chest level to prevent backflow of drainage.

D. Ensure 2 cm (0.8 in) of water is in the water seal chamber – Correct. The water seal chamber maintains negative pressure and prevents air from entering the pleural space, making this a crucial step in chest tube management.

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A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?

Nursing Test Bank

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