A nurse is assessing a toddler at a well-child visit.
At what point in the physical examination should the nurse examine the child's tympanic membrane?
At the beginning.
Before auscultating the chest and abdomen.
Before examining the head and neck.
At the end.
The Correct Answer is D
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
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Correct Answer is C
Explanation
Choice A rationale
The Industry vs. Inferiority stage, according to Erikson, occurs from age 6 to puberty, where children focus on learning, developing skills, and striving for competence. A 20-month-old
child is not yet in this stage.
Choice B rationale
The Trust vs. Mistrust stage is the earliest stage in Erikson's theory, occurring from birth to about 18 months. While a 20-month-old child has recently transitioned out of this stage, it
is not the stage applicable to their current developmental phase.
Choice C rationale
The Autonomy vs. Shame and Doubt stage occurs from approximately 18 months to 3 years. At 20 months, children are striving for independence, making choices, and developing a
sense of self-control, which is characteristic of this stage.
Choice D rationale
The Initiative vs. Guilt stage occurs from ages 3 to 6 years, where children begin to assert power and control through directing play and other social interactions. A 20-month-old child
is not in this stage yet.
Correct Answer is B
Explanation
Choice A rationale
A pincer grasp, using the thumb and index finger to pick up small objects, typically develops around 9 to 12 months of age, not at 4 months.
Choice B rationale
The posterior fontanel typically closes by the age of 2 to 3 months, so a 4-month-old infant would be expected to have a closed posterior fontanel. This finding is consistent with normal development.
Choice C rationale
Lateral incisors, the teeth on either side of the front teeth, typically erupt around 9 to 13 months of age, not at 4 months.
Choice D rationale
Sitting steadily without support generally occurs closer to 6 to 8 months of age, so it would not be expected in a 4-month-old infant.