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 D
Explanation
Choice A reason:
Providing detailed information about the procedure is important, but the first step in obtaining informed consent is to ensure that the parent understands the information. This can be achieved by assessing their understanding.
Choice B reason:
Discussing the benefits of the procedure is part of providing information for informed consent, but it should come after assessing the parent's understanding.
Choice C reason:
Explaining the risks associated with the procedure is important, but the first step is to ensure the parent comprehends this information, which can be achieved through assessment.
Choice D reason:
This statement is correct. Before proceeding with detailed information, it is essential to determine the parent's current understanding of the procedure to ensure they can make an informed decision.
Correct Answer is B
Explanation
Choice A reason:
Administering digoxin should be based on the infant's specific heart rate and the healthcare provider's prescription, rather than a specific pulse value.
Choice B reason:
Allowing for frequent rest periods is important for an infant with heart failure, as it helps conserve energy and reduce cardiac workload.
Choice C reason:
Feeding duration should be based on the infant's tolerance and ability to feed effectively, rather than a specific time frame.
Choice D reason:
Maintaining the infant in a supine position can help with respiratory function but should be balanced with appropriate positioning to prevent aspiration and promote comfort. It is not the sole action to include in the plan of care.
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