A nurse is assessing a 24-month-old toddler. Which of the following findings should the nurse report to the provider?

- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.

- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.

- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.

- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.

A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.

B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.

C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.

D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.