A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

Superficial scrapes on the toddler's lower legs

Circular burns on the soles of the toddler's feet

Irregular area of blue pigmentation over the toddler's sacrum

Single bruise on the toddler's forearm

Answer and Explanation

The Correct Answer is B

A. Superficial scrapes on the toddler's lower legs: These are common in toddlers due to normal play and exploration.
B. Circular burns on the soles of the toddler's feet: Circular burns, especially in unusual areas like the soles, are a hallmark sign of intentional injury and potential abuse.
C. Irregular area of blue pigmentation over the sacrum: This is likely a Mongolian spot, a benign and common finding in children of certain ethnicities.
D. Single bruise on the toddler's forearm: This is not necessarily indicative of abuse, as toddlers frequently sustain minor injuries from routine activities.

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Correct Answer is C

Explanation

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. The correct insertion depth is 2.5 cm (1 inch) for toddlers to avoid rectal injury.
B. Place the child in prone position. The child should be placed in the side-lying or supine position with legs flexed.
C. Stabilize the thermometer at the distal end. Stabilizing the thermometer ensures it remains in position during the procedure, minimizing risk of injury.
D. Direct the tip of the thermometer toward the spine during insertion. The thermometer should be directed toward the umbilicus to follow the natural rectal curve.

A. Administer IV antibiotics. B. Monitor vital signs. C. Encourage oral fluids. D. Initiate droplet precautions.

Correct Answer is D

Explanation

A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.

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A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

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