A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?
Can draw a circle.
Has a vocabulary of four words.
Jumps with both feet.
Weighs 12 kg (26.5 Ib).
The Correct Answer is B
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Correct Answer is B
Explanation
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
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