A nurse is collecting data from a 3-year-old child during a well-child visit.

Which of the following findings should alert the nurse to a possible developmental delay?

The child speaks in three-word sentences

The child copies a circle with a crayon

The child rides a tricycle using pedals

The child has frequent temper tantrums

Answer and Explanation

The Correct Answer is D

The child has frequent temper tantrums. This is because temper tantrums are not a normal part of a 3-year-old child’s development and can indicate emotional or behavioral problems. According to the height and weight chart for children, a 3-year-old child should be able to do the following:

• Speak in three-word sentences

• Copy a circle with a crayon

• Ride a tricycle using pedals

Therefore, choices A, B and C are wrong because they are expected developmental milestones for a 3-year-old child.

A nurse should collect data from the child and the parents to determine the cause and frequency of the temper tantrums and provide appropriate interventions and referrals.

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Correct Answer is D

Explanation

Growth and development evaluation should be done annually until adulthood, plotted on appropriate growth charts and compared with expected norms for age and sex, and used to identify any deviations from normal or expected patterns of growth and development.

Choice A is wrong because growth and development evaluation should not be done only annually, but also at specific ages recommended by the American Academy of Pediatrics (AAP), such as 9 months, 18 months, 24 months, and 30 months.

Choice B is wrong because growth and development evaluation should not only be plotted on appropriate growth charts and compared with expected norms for age and sex, but also include developmental milestones in playing, learning, speaking, behaving, and moving.

Choice C is wrong because growth and development evaluation should not only be used to identify any deviations from normal or expected patterns of growth and development, but also to monitor the child’s progress and provide early intervention if needed.

A. Mix the medication with a small amount of formula in a bottle B. Use an oral syringe to squirt the medication into the side of the mouth C. Place the medication on a pacifier and let the infant suck on it D. Dip a cotton swab in the medication and rub it on the gums

Correct Answer is B

Explanation

Use an oral syringe to squirt the medication into the side of the mouth.

This is because an oral syringe allows the nurse to measure the exact dose of the medication and deliver it slowly and safely into the infant’s mouth, avoiding choking or aspiration.

The other choices are wrong for the following reasons:

• Choice A) Mixing the medication with formula in a bottle can alter the taste and effectiveness of the medication, and also make it difficult to ensure that the infant receives the full dose.

• Choice C) Placing the medication on a pacifier can cause the infant to spit out the pacifier or the medication, and also increase the risk of infection from contaminated pacifiers.

• Choice D) Dipping a cotton swab in the medication and rubbing it on the gums can irritate the oral mucosa and cause pain or bleeding, and also waste some of the medication on the swab.

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A nurse is collecting data from a 3-year-old child during a well-child visit. Which of the following findings should alert the nurse to a possible developmental delay?

Nursing Test Bank

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Correct Answer is B

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A nurse is collecting data from a 3-year-old child during a well-child visit.

Which of the following findings should alert the nurse to a possible developmental delay?