The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?
The child exhibits plantar grasp reflex.
The child has doubled his birth weight.
No primary teeth have erupted yet.
The child's head circumference is 49.53 cm.
The Correct Answer is C
A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months
is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.
B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.
C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.
D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.
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Correct Answer is B
Explanation
A. Vary the child's schedule each day: While some variation in activities may be beneficial, providing a stable and predictable routine can also promote a sense of security and stability for the child during hospitalization.
B. According to Erikson's psychosocial development theory, the psychosocial stage for a 10- year-old child is industry versus inferiority. During this stage, children are developing a sense of competence by mastering new skills and tasks. Encouraging the child to complete school work supports this developmental stage by fostering a sense of accomplishment and competence. It
also helps maintain a sense of normalcy and continuity with academic activities despite the hospitalization.
C. Discourage visits from the client's friends: Social interaction with peers is important for the child's emotional well-being and development. Discouraging visits from friends would likely have a negative impact on the child's psychosocial needs during hospitalization.
D. Provide a daily session with a play therapist: While play therapy may be beneficial for addressing emotional needs, it may not directly address the child's psychosocial development according to Erikson's theory. Encouraging completion of school work aligns more closely with the developmental tasks of this stage.
Correct Answer is A
Explanation
A. "Tell me about the circumstances when this occurs.": This response allows the nurse to gather more information about the child's toileting habits and potential triggers for the accidents.
Understanding the context can help identify possible underlying causes and guide appropriate interventions.
B. "Is there a family history of diabetes?": While diabetes can be a cause of increased urination, asking about a family history of diabetes is premature and may unnecessarily alarm the parent before further assessment.
C. "Suddenly having accidents can be a sign of diabetes.": Jumping to conclusions about a serious medical condition like diabetes without further assessment or evidence can cause unnecessary anxiety for the parent. It's important to gather more information and consider other potential causes before suggesting a diagnosis.
D. "That's normal: don't worry about it.": While occasional daytime wetting accidents can be common in young children, dismissing the concern without further assessment may overlook potential underlying issues that could benefit from intervention or support.
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