A 2-year-old has been admitted to the pediatric unit with a 2-day history of vomiting and diarrhea. Which of the following would be a cue the nurse identifies as being outside the normal standard?
1. The child's weight is 25 lb.
2. The child cries when parents leave the room.
3. The child is not able to stand alone.
4. The child is able to hold finger foods.
Correct Answer: 3
Rationale: A developmental delay that should cue the nurse to a probable problem would be that this 2-year-old is not able to stand by himself. Most children are walking between 12 months and 18 months. The other data are considered normal behavior for a 2-year-old.
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