A nurse is collecting data from an 18-month-old toddler. Which of the following findings should the nurse report to the provider?
Speaks four words
Builds a tower of three blocks
Has temper tantrums
Jumps in place with both feet
The Correct Answer is A
Choice A reason:
At 18 months, a toddler should typically be saying more than four words. This finding may
indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.
Choice B reason:
Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Choice C reason:
Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.
Choice D reason:
Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.
Choice B reason:
Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.
Choice C reason:
Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.
Choice D reason:
A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.
Correct Answer is B
Explanation
Choice A reason:
Placing a urine collection device on the infant is not an appropriate method for collecting a stool specimen.
Choice B reason:
Obtaining the specimen by swabbing the infant's rectum using a sterile culture swab is the correct method for collecting a stool specimen from an infant.
Choice C reason:
Maintaining the specimen at room temperature is appropriate after collection until it is transferred to the lab. This is standard procedure for many specimens.
Choice D reason:
Using povidone-iodine-soaked gauze is not a standard method for transferring a stool specimen to the collection container.
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