A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Refer the child to social work for early intervention.
Educate the parents on the developmental delays their child is diagnosed with.
Provide the parents with pamphlets for support groups for children with developmental delays.
Discuss the assessment findings with the primary care provider.
The Correct Answer is D
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
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Correct Answer is D
Explanation
Choice A rationale
Erikson’s stage of initiative versus guilt occurs in preschool-aged children (3-5 years), not toddlers.
Choice B rationale
Imaginary playmates are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice C rationale
Demonstrations of sexual curiosity are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice D rationale
Negative behaviors characterized by the need for autonomy are typical in toddlers. This stage, according to Erikson, is autonomy versus shame and doubt, where toddlers strive for independence and self-control.
Correct Answer is A
Explanation
Choice A rationale
Placing the child in a knee-chest position helps increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation during a cyanotic spell in children with Tetralogy of Fallot.
Choice B rationale
Having the child lie supine with the head turned to one side does not help in managing a cyanotic spell and may not improve oxygenation.
Choice C rationale
Lying prone does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.
Choice D rationale
Placing the child in a semi-Fowler’s position in an infant seat does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.