A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect?
Walks backwards heel to toe
Stands on one foot for a few seconds
Skips and hops on one foot
Has a vocabulary of 1500 words
The Correct Answer is B
At the age of 3, children typically start to develop better balance and coordination. They may be able to stand on one foot for a short period of time, although their ability to maintain balance may vary.
Walking backward heel to toe, skipping, and hopping on one foot are typically achieved around the age of 4-5 years.
As for vocabulary, a 3-year-old child may have a vocabulary of approximately 300-500 words, although the exact number can vary. A vocabulary of 1500 words is more commonly seen in older children.
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Correct Answer is C
Explanation
A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.
B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.
C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.
D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.
Correct Answer is B
Explanation
While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn.
It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
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