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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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Correct Answer is D

Explanation

Choice A rationale

Explaining the difference between right and wrong is a developmental task expected of older children, typically preschoolers or early school-aged children. Toddlers are still developing their understanding of rules and consequences.

Choice B rationale

Printing letters and numbers is a skill expected of preschoolers or early school-aged children. Toddlers are still developing fine motor skills and are not yet capable of printing letters and numbers.

Choice C rationale

Cooperating in doing simple chores is a developmental task that can be expected of toddlers. However, it is not as specific or significant as the ability to separate easily from the primary caregiver for short periods of time, which is a key developmental milestone for toddlers.

Choice D rationale

Separating easily from the primary caregiver for short periods of time is an important developmental milestone for toddlers. It indicates that the child is developing a sense of independence and trust in their environment, which is crucial for their social and emotional development.

Correct Answer is A

Explanation

Choice A rationale

The FLACC scale (Face, Legs, Activity, Cry, Consolability) is suitable for assessing pain in infants and young children who cannot verbally communicate their pain. It evaluates five criteria to determine the level of pain.

Choice B rationale

The FACES scale is more appropriate for children aged 3 years and older who can point to the face that best represents their pain level.

Choice C rationale

The OUCHER scale is also designed for older children who can understand and use the photographic or numerical scale to indicate their pain.

Choice D rationale

The PANAD scale is used for assessing pain in patients with advanced dementia and is not suitable for infants.

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