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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?

A.

Refer the child to social work for early intervention.

B.

Educate the parents on the developmental delays their child is diagnosed with.

C.

Provide the parents with pamphlets for support groups for children with developmental delays.

D.

Discuss the assessment findings with the primary care provider.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Developing autonomy is a normal developmental milestone for toddlers. However, the behaviors described in the question (sitting quietly, sucking thumb, turning away) are more indicative of regression rather than autonomy.

Choice B rationale

Resentment toward the mother is not a typical developmental reaction for an 18-month-old toddler. The behaviors described are more indicative of regression due to the stress of hospitalization.

Choice C rationale

Anxiety reaction can occur in toddlers who are hospitalized, but the behaviors described (sitting quietly, sucking thumb, turning away) are more indicative of regression.

Choice D rationale

Regression is a common reaction in toddlers who are hospitalized. The behaviors described (sitting quietly, sucking thumb, turning away) are typical signs of regression, where the child reverts to earlier developmental behaviors as a coping mechanism.

Correct Answer is A

Explanation

Choice A rationale

Auscultating the rate and characteristics of the child’s heart sounds is the priority assessment. Acute rheumatic fever can lead to carditis, which affects the heart valves and can cause new or changed heart murmurs.

Choice B rationale

Assessing the client’s erythematous rash is important but not the priority. The rash is a common symptom but does not indicate the severity of the condition.

Choice C rationale

Identifying the degree of parental anxiety is important for providing holistic care but is not the immediate priority in assessing the child’s physical condition.

Choice D rationale

Using a pain-rating tool to determine the severity of joint pain is important for managing symptoms but is not the priority assessment upon admission.

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