The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

The toddler's anterior fontanel is not fully closed.

The toddler gained 3 in in height since last year.

The toddler gained 4 lb in weight since last year.

The circumference of the child's head increased 1 in since last year.

Answer and Explanation

The Correct Answer is A

A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.

B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.

C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.

D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.

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Correct Answer is ["C","D","E"]

Explanation

A. Use mummy restraints during painful procedures: Using restraints may increase the child's anxiety and resistance, exacerbating the fear of procedures. It is important to minimize any factors that may increase the child's distress during procedures.

B. Perform the procedure as quickly as possiblE. While it is important to minimize the duration of procedures to reduce discomfort, rushing the procedure excessively may increase the child's

anxiety and make the experience more traumatic. A balance should be struck between efficiency and ensuring the child feels comfortable and secure.

C. Have a parent stay with the child during procedures: Having a familiar caregiver present can provide comfort and reassurance to the child during procedures. The presence of a parent can help the child feel safe and supported, reducing anxiety and fear.

D. Cluster invasive procedures whenever possiblE. Clustering invasive procedures minimizes the frequency of painful experiences for the child, reducing overall distress and anxiety. This approach also allows the child to have longer periods of comfort between procedures.

E. Allow the child to keep a toy from home with her: Providing a familiar toy or comfort item can serve as a distraction and source of comfort for the child during procedures. Allowing the child to hold onto something familiar can help reduce anxiety and provide a sense of security.

A. Myelination of the brain and spinal cord is complete at about 24 months. B. Alveoli reach adult numbers by 3 years of age. C. Urine output in a toddler typically averages approximately 30 mL/hour. D. Toddlers typically have strong abdominal muscles by the age of 2.

Correct Answer is A

Explanation

A. Myelination of the brain and spinal cord is a continuous process that begins during fetal development and continues through childhood and adolescence. While significant myelination

occurs during infancy and toddlerhood, it is not complete by 24 months. However, substantial progress in myelination does occur during the toddler years, contributing to the development of motor and cognitive skills.

B. Alveoli reach adult numbers by 3 years of age. This statement is incorrect. Alveoli continue to develop and increase in number after birth, reaching adult numbers around adolescence, not by 3 years of age.

C. Urine output in a toddler typically averages approximately 30 mL/hour. This statement is incorrect. Toddlers typically have higher urine output rates than adults due to their smaller

bladder capacity and higher metabolic rate. The average urine output for a toddler is around 1-2 mL/kg/hour, which varies depending on factors such as hydration status and activity level.

D. Toddlers typically have strong abdominal muscles by the age of 2. This statement is incorrect. While toddlers may develop some abdominal muscle strength through activities such as walking and climbing, their muscle tone and strength are still developing and may not be as strong as in older children or adults.

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The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

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Explanation

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Correct Answer is A

Explanation

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