A nurse is participating in the care of a 4-year-old child as part of the interdisciplinary team. Which of the following observations should the nurse report to the physical therapist?

The child is unable to skate with good balance.

The child is unable to jump rope.

The child is unable to walk downstairs on alternating feet.

The child is unable to walk backwards from heel to toe.

Answer and Explanation

The Correct Answer is C

A) The child is unable to skate with good balance.
At 4 years old, a child’s balance and coordination are still developing. While skating requires more advanced skills, a child not having good balance at this age is not typically a concern unless other motor skills are delayed. Skating is not an expected milestone for a 4-year-old.

B) The child is unable to jump rope.
Jumping rope is a more complex skill that typically develops later, closer to ages 5 or 6, so the inability to do so at age 4 is not a cause for concern. It is a skill that requires fine motor coordination, balance, and timing, which may not be fully developed at this age.

C) The child is unable to walk downstairs on alternating feet.
At 4 years old, children are expected to be able to walk downstairs using alternating feet (one foot on each step). If a child cannot perform this task, it may indicate a delay in gross motor development, specifically in coordination and balance. This is a developmental milestone that typically emerges by age 4 and should be reported to the physical therapist for further evaluation.

D) The child is unable to walk backwards from heel to toe.
Walking backwards from heel to toe is a more advanced skill that typically develops later in childhood. This skill is not expected at age 4, so the child’s inability to do so is not a red flag for developmental concerns. It is more appropriate for older children.

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Correct Answer is D

Explanation

A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.

B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.

C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.

D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.

A. I have a difficult time getting my child to eat green vegetables B. My child continually asks me the same questions C. My child still wets the bed at least two times per week D. I have noticed that my child is withdrawn since we switched day care providers

Correct Answer is D

Explanation

A) I have a difficult time getting my child to eat green vegetables: While it’s common for preschoolers to be selective about food, especially vegetables, this issue does not represent an immediate concern for the child’s health or development. This issue can often be addressed with strategies to encourage healthy eating, but it is not as urgent as other concerns.

B) My child continually asks me the same questions: Repetitive questioning is a normal part of preschool development, as children at this age are curious and often seek reassurance. It reflects their cognitive development as they try to understand the world around them. While it may be tiring for the guardian, it is not an immediate concern.

C) My child still wets the bed at least two times per week: Bedwetting (enuresis) is common among preschool-aged children, and many children do not gain full bladder control until after age 5. This issue is typically addressed if it continues past the age of 5, but it is not a priority at this time.

D) I have noticed that my child is withdrawn since we switched day care providers: This statement indicates a potential emotional or behavioral issue that requires immediate attention. Changes in behavior, such as withdrawal, can be a sign of stress, anxiety, or difficulty adjusting to a new environment. The nurse should prioritize this concern, as it may indicate that the child is having difficulty coping with the transition and may need additional support or evaluation. Addressing emotional well-being is a priority for the nurse.

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A nurse is participating in the care of a 4-year-old child as part of the interdisciplinary team. Which of the following observations should the nurse report to the physical therapist?

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