Vital Signs & Assessment
What is the best way to count the heart rate in a toddler?
By auscultating the apical pulse for 1 full minute.
Name 2 vaccines given at the 2-month visit.
DTaP, Hib, IPV, PCV13, HepB, RV
According to Erikson, what is the primary stage for a toddler (age 1–3 years)?
Autonomy vs. Shame and Doubt.
How long should time-outs be for a 4-year-old?
4 minutes (1 min per year of age).
Where should injections be given to an infant under 12 months?
Vastus lateralis muscle.
At what age do you begin routine blood pressure measurement during physical exams?
Age 3 years.
Which vaccines are introduced at 12 months of age?
MMR, Varicella, HepA, PCV13 booster.
At what age does stranger anxiety usually peak?
6–18 months.
Which discipline method is NOT recommended for preschoolers: logical consequences, positive reinforcement, or spanking?
Spanking.
Why should painful procedures not be done in the child’s hospital room?
Keep the room a safe space — use treatment rooms for procedures.
Which ear position is correct for tympanic temps in children under 3?
Pull the pinna down and back.
At the 5-year well visit, which “kindergarten shots” are given?
DTaP, IPV, MMR, Varicella.
A 24-month-old uses 2-word sentences like “me go.” Is this appropriate?
Yes, expected at 24 months.
A toddler insists on brushing his own teeth. What should parents do?
Allow independence, then assist for thorough cleaning.
Name one nonpharmacologic technique to help infants tolerate painful procedures.
Oral sucrose/pacifier, distraction, swaddling, kangaroo care.
Which pain scale is most appropriate for an infant after surgery?
CRIES scale.
What key information must always be documented after giving an immunization?
Date, vaccine given, manufacturer, lot number, site/route, provider.
What is the purpose of the Denver II developmental screening tool?
Screening for developmental delays (not diagnostic).
A parent says, “My preschooler is hyper at bedtime, so he must need less sleep.” What is the nurse’s response?
Hyperactivity at bedtime often means the child is overtired.
What nursing action helps promote normal development for a school-age child who is hospitalized?
A 4-year-old child has persistent strabismus. Should this be referred to an ophthalmologist? Why?
Yes, strabismus after age 4 is abnormal and needs referral.
True or False: You may give an MMR vaccine to an infant who recently received immune globulin. Explain.
False — live vaccines must be delayed after immune globulin.
Give one red flag for developmental delay.
head lag after 4 months, no sitting by 9 months, no words by 18 months.
What teaching should the nurse give parents to prevent accidental poisonings?
Store all toxic agents and medicines in locked cabinets.
A nurse notices conflicting stories about a child’s injury. What is the nurse’s responsibility?
Mandatory reporting of suspected abuse.