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 D

Explanation

A. Negative behaviors characterized by the need for autonomy: While toddlers may exhibit negative behaviors as they assert their independence, this is not the defining characteristic of psychosocial development during this stage.

B. Demonstrations of sexual curiosity: Sexual curiosity typically emerges during the preschool and early school-age years rather than during toddlerhood.

C. Imaginary playmates: Imaginary playmates are more commonly seen during the preschool years, not necessarily during toddlerhood.

D. Erikson's stage of initiative versus guilt: This stage, occurring during early childhood (ages 3 to 6 years), is characterized by the child's growing sense of initiative in exploring and interacting with the world balanced against the potential for feeling guilty about their actions. It involves developing a sense of purpose and direction in life while navigating feelings of competence versus inadequacy.

A. Has a fear of strangers B. Uses a unidextrous grasp C. Babbles one-syllable sounds D. Shows preferences towards foods

Correct Answer is B

Explanation

A. Has a fear of strangers: Fear of strangers typically emerges around 6 to 9 months of age as part of normal social development. While it indicates cognitive and emotional growth, it does not necessarily warrant further evaluation unless it is excessive or accompanied by other concerning behaviors.

B. Uses a unidextrous grasp: By 7 months, infants typically develop a more refined pincer grasp, where they can pick up small objects using the thumb and forefinger (bidextrous grasp). A unidextrous grasp (using only one hand) may suggest a delay in fine motor development and could warrant further evaluation by a healthcare provider.

C. Babbles one-syllable sounds: Babbling is a typical milestone in language development for

infants around 6 to 9 months of age. One-syllable babbling is expected at this stage and does not necessarily indicate a need for further evaluation.

D. Shows preferences towards foods: Developing food preferences is part of normal feeding behavior for infants. While it is important to ensure a balanced diet, showing preferences towards certain foods is not typically a cause for concern at this age.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?

Correct Answer is D

Explanation

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?

Correct Answer is B

Explanation

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