A nurse is collecting data from a 7-year-old child. Which of the following findings indicates a developmental delay?

Unable to verbalize the date

Unable to count backwards from 20 to 1

Unable to make change out of a quarter

Unable to tell the difference between right and left

Answer and Explanation

The Correct Answer is D

A: By the age of 7, most children have a grasp of days and dates as part of their routine. However, not being able to verbalize the date does not necessarily indicate a developmental delay, as it could be related to the child's learning environment or educational opportunities.

B: Counting backwards is a skill that develops with age and practice. A 7-year-old may struggle with this task due to various reasons such as lack of practice, but it is not a definitive sign of a developmental delay.

C: Making change involves complex cognitive skills including math, understanding of money value, and transactions, which may still be developing in a 7-year-old. This skill varies widely among children and is influenced by their experiences with money.

D: The ability to distinguish right from left is a developmental milestone typically achieved by the age of 5 to 6 years. Persistent difficulty in telling the difference between right and left at the age of 7 could suggest a developmental delay in spatial awareness.

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Correct Answer is D

Explanation

Rationale:

A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.

B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.

C) A respiratory rate of 40/min is within the normal range for an infant.

D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.

A. Give 1 tsp of peanut butter to the child. B. Recheck the child's blood glucose level. C. Administer 1 tbsp of sugar to the child. D. Document the incident in the child's record.

Correct Answer is C

Explanation

Rationale:

A) Peanut butter is not a rapidly absorbed source of glucose and may not be appropriate for treating hypoglycemia.

B) While rechecking the child's blood glucose level is important, immediate treatment should be initiated for symptomatic hypoglycemia.

C) Administering a rapidly absorbed source of sugar, such as 1 tablespoon of sugar or honey, is the priority intervention for treating hypoglycemia in a conscious child.

D) Documenting the incident is important but should not delay the administration of treatment for hypoglycemia.

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A nurse is collecting data from a 7-year-old child. Which of the following findings indicates a developmental delay?

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