The nurse is assessing an 18-month-old patient at a well-child visit. What findings would suggest a developmental delay?

Says two-word sentences.

Uses pincer grasp to eat Cheerio’s.

Removes shoes and socks.

Prefers to use the right hand.

Answer and Explanation

The Correct Answer is D

Choice A reason: Saying two-word sentences is an expected developmental milestone for an 18-month-old child. At this age, children should begin combining two words to form simple sentences, such as "more juice" or "mama go." This indicates normal language development.

Choice B reason: Using a pincer grasp to eat Cheerio’s is a typical fine motor skill for an 18-month-old child. The ability to pick up small objects between the thumb and forefinger demonstrates proper development of fine motor skills and hand-eye coordination.

Choice C reason: Removing shoes and socks is a common developmental milestone for an 18-month-old child. This task shows growing independence and the ability to perform basic self-care activities, which is a sign of normal development.

Choice D reason: Preferring to use the right hand may suggest a developmental delay because children typically do not show a strong hand preference (left or right) until around the age of 2 to 3 years. Early hand dominance can be a sign of an underlying issue, such as asymmetry in muscle strength or neurological development. It is important to assess further if a child shows a strong preference for one hand at this early age.

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Correct Answer is C

Explanation

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

A. My baby has a higher risk of developing jaundice. B. This procedure was required because my baby was breech. C. The vacuum was required because I did not dilate past 6 centimetres. D. My baby’s head will be cone-shaped for about 2 months.

Correct Answer is A

Explanation

Choice A reason: This statement indicates the parent's understanding that vacuum-assisted deliveries can sometimes lead to an increased risk of jaundice. The use of a vacuum can cause bruising on the baby's scalp, which can lead to the breakdown of red blood cells, thereby increasing bilirubin levels. Elevated bilirubin levels can cause jaundice in newborns. Recognizing this potential risk and monitoring the baby for signs of jaundice is an essential aspect of post-delivery care.

Choice B reason: Stating that the procedure was required because the baby was breech is incorrect. Vacuum-assisted delivery is typically used in cases where the baby is in a cephalic (head-first) position and there are difficulties in progressing through the birth canal, such as when the mother is exhausted, or the baby needs to be delivered quickly due to fatal distress. Breech presentations often necessitate a caesarean section instead of a vacuum-assisted delivery.

Choice C reason: The assertion that the vacuum was required because the mother did not dilate past 6 centimetres is inaccurate. Vacuum-assisted delivery is not related to cervical dilation but rather to difficulties encountered during the second stage of Labor (pushing phase). The decision to use a vacuum is made when the baby is in the birth canal, and additional assistance is needed to facilitate delivery.

Choice D reason: Stating that the baby’s head will be cone-shaped for about 2 months is also incorrect. While a vacuum-assisted delivery can result in a temporary cone-shaped head (known as "caput succedaneum" or melding), this typically resolves within a few days to weeks after birth. It is not expected to last for two months. Proper education should clarify the temporary nature of the head shape changes.

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The nurse is assessing an 18-month-old patient at a well-child visit. What findings would suggest a developmental delay?

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Correct Answer is A

Explanation

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