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 developmental delay?

Runs with a wide stance.

Falls when throwing a ball overhand.

Refers to self by name.

Goes up stairs with two feet on each step.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.

Choice B rationale:

Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.

Choice C rationale:

Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.

Choice D rationale:

Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.

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Correct Answer is D

Explanation

A. Incorrect. Releasing the tourniquet is a step that can be taken after advancing the catheter into the vein.

B. Incorrect. Retracting the stylet at this point could disrupt the position of the catheter and cause leakage or damage.

C. Incorrect. Flushing the catheter with saline is an appropriate step after ensuring the catheter is correctly placed in the vein.

D. Correct. After noting a blood return in the flashback chamber, the next step is to advance the catheter into the vein to ensure proper placement for intravenous access.

A. A client who is receiving heparin for deep-vein thrombosis B. A client who is 1 day postoperative following a vertebroplasty C. A client who has COPD and a respiratory rate of 44/min D. A client who has cancer and a sealed implant for radiation therapy

Correct Answer is B

Explanation

A. Incorrect. A client receiving heparin for deep-vein thrombosis should not be discharged early.
B. Correct. This client is the most appropriate candidate for early discharge in anticipation of multiple client admissions. Vertebroplasty is a minimally invasive procedure that typically requires only a short hospital stay. The client is likely stable at 1 day post-procedure and can be discharged with appropriate follow-up care.
C. Incorrect. A client with COPD and a respiratory rate of 44/min needs immediate attention, not early discharge.
D. Incorrect. This client is stable for discharge, as sealed radiation implants typically do not require hospitalization after a certain point, assuming they are stable and able to manage their care at home. Discharging this client can help free up resources for incoming patients, provided they have appropriate support at home.

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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 developmental delay?

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Correct Answer is D

Explanation

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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 developmental delay?