Hi! This is Diana Shenefield. And today, we’re
going to talk about Developmental Stages and
Transitions which is really important on the
NCLEX exam, and a lot of times people think
that it’s only important for pediatrics,
but we’re going to talk a little bit more
about the older people as well because they
kind of get forgotten.
So our overview is, again, this is really important
for NCLEX. I know you know from your pediatric
class that you dealt a lot with growth and
development. And so you’re going to want
to review that. So today, we’re going to do a
really fast review of growth and development.
But again, we’re going to not stop at teenagers.
We’re going to go on to the older adult
as well. So we have learning outcomes just like
we do for every single class, the things that
we’re going to want to learn while we’re
taking this class. I want you to read through
those learning objectives. And if there are
any of them at the end of this program that
we didn’t meet or that you feel like you
need more practice on, that’s where I want
you to focus on your study time. So, first
of all, we’re going to start off
with a question. So a nurse is assessing a 6-month-old
infant. What following reflexes should the
6-month-old have? This is one of the questions
that NCLEX is probably going to ask you because
it’s really important that you know when
the primitive reflexes disappear. Is it
moro, plantar grasp, stepping, or tonic neck?
Again, in your mind, review what those are.
And hopefully, you picked plantar grasp because
that doesn’t disappear until about the eighth
or ninth month. Let’s try another one.
So, you have a parent
and they’re discussing behavior with you.
And a lot of times, we know as nurses, parents
want to know what’s normal, what’s
not normal. So in NCLEX, it’s important
that you know that. So here, we have a three-year-old,
and what is normal for the three-year-old?
Is it A, saying no often? Is it B, using a
limited vocabulary about 500 to 3000 words?
Is it C, speaking in 10-word sentences? Or is
it D, believing that adults know everything?
So think of that three-year-old that you’ve taken
care of. Hopefully, you picked C, speaking
in 10-word sentences. They can’t put that
many words together. So again, if you had
trouble with that, you want to go back and
review your toddler.
So we’re going to start with infants,
best place to start. We’re going to think
about what's the physical things that are
going on with infants. And you’ll see on
the screen that we have primitive reflexes,
and that’s what we just talked about in
that first slide. We also have what is normal
for the infant. We know infants change a lot
from day 28 until they’re 12 months old.
So there're a lot of reviews there.
We’re going to talk about fontanel closing. You
know by doing infant assessments that the
fontanel is really important for neurological
and for behavioral. So you want to make sure
you know that. And then ability to gain head
control, that’s a big deal, and then birth
weight should triple. So when that infant
comes into the doctor’s
office or into the hospital, you need to make
sure you know where they fit on that growth
development curve. And then, are they making
vocal sounds? Can they recognize their own
name? Now, we know a 28-day-old isn’t going
to, but by the time they get to the near end
of infant, 11, 12 months old, they should
turn their head when you call their name.
And then, stranger anxiety. Stranger anxiety
hasn’t started till about six months.
So after six months, they should be afraid when
a stranger comes around or somebody else wants
to hold them. And then we all know
Erikson. Erikson is really
important. If you had trouble memorizing Erikson,
that’s one that you do need to memorize.
And we had trust versus mistrust. And later
on in this talk, we’re going to talk about
how do I know if they’re not meeting that
developmental stage. Now, toddlers. It’s
really important too that you know the ages.
And toddlers are one and two-year-olds. So again,
put in your mind those patients that you’ve
taken care of, nieces and nephews. Are they
walking? And how did they learn to run? Can
they ride a tricycle? Now, a one-year-old
probably can’t ride a tricycle, but by the
time they’re two moving into the three-year-old,
they should be riding a tricycle. Can they
feed themselves? And what all parents want
to know is when will they be potty trained.
So cognitively, they should be able to obey simple
commands. When you tell them to pick up their
toys, they should be able to do that.
Now, they’re not going to be able to do a lot
of instructions all at one time, but one at
a time, they should be able to do. Their speech
should be more understandable. Now, by what
I mean by more understandable is that you
may not understand every single word that
they say because they’re going to blabber a lot.
But you should be able to start understanding
more common words more clear. And then,
toddlers are going to want to seek
your attention. Have you ever been around
the toddler when they’re talking to you
and if you’re not right looking at them,
they’ll grab your face, and want you to
look right at them? They want to know that
you’re paying attention to them. And then
psychosocial, we’ve got Erikson again, autonomy
versus shame and doubt. So we’re going to
review that. Also, it’s real important about
this time that children start playing.
And we know toddlers like to play by themselves.
They may have other kids playing at the day
care, but they usually aren’t playing together.
Preschoolers. Preschoolers is one of the
fun ages because they are trying to see what’s
going on in the whole world. They are into
everything. They are going to be more coordinated.
You’re going to see them picking up balls
and throwing them. They’re going to be able
to dress themselves. Now, to the dismay of
many parents, they may not pick up clothes
that match but they should be able to put
on their own clothes. And they should be able
now to be able to walk up and down the stairs
without any problems. Cognitively, they are
aware of limits. They’re starting to learn
rules. Where the toddler didn’t so much
know the rules, preschoolers are starting
to follow rules. They also have a vocabulary
way into the thousands. They’re able to
draw shapes. These are the kids that want
to color. They may not stay in the lines,
but they should be able to make a circle.
They should be able to make straight lines.
They should be able to try to draw a stick
And then, this is where it gets a little tricky.
They want to copy mom and dad. You’ll see
them playing house, playing school, trying
to mow the yard. So again, they’re really
watching their parents and trying to do what it is
that they are doing. And then psychosocially,
we got initiative versus guilt according
School age, so now they’re off to school.
Lot of growths spurts. Boys, especially.
You’ll notice parents will say, “I think
they grew two inches over the summer.”
Lots of growths spurt. They may go periods of time
where they don’t grow, and then all of a
sudden, they grow a lot, and that’s normal
for them. They’re probably skipping and
jumping rope. That’s a coordination that
preschoolers can’t do, that you can’t do
until about the time that you’re in school
age. And then riding a bike, they should be
able to ride a two-wheel bike. Cognitively,
this is when they’re learning
to read and right. And a lot of times, we
find out that maybe they’re dyslexic or
they’re having hearing problems because
they’re not reading and writing, or vision
problems, when the teacher says that they
didn’t seem like they can see the front
of the class. So a lot of times, those kinds
of things aren’t caught until they get into
school age. And then according to Erikson,
the industry versus inferiority. And now, we’re
starting to see the cooperative play where
they’ll play games with other children.
Teenagers. Big physical thing is puberty.
We all have been through puberty. We all know
the struggles. So these kids, we’re watching
for normal development and abnormal development.
They have a lot of interests in their personal
appearance, and they’re very involved in
sports, extracurricular activities. You want
to watch for the kids that don’t seem to
be involved. Cognitively, they really care
about what their peers think about them.
And so that guides a lot of their behavior. And
they are into a lot of risks taking. So there’s
a lot of education for the nurses. And by now,
they can do abstract thinking. They should
be thinking like an adult. They should be
able to follow rules and they should be able
to think things through without making impulse
decisions. And according to Erikson, they’re
in the identity versus role confusion. Now, we
get to the adult where sometimes it
gets left off, especially in pediatrics. But
physical peak for an adult is 25 to 35.
After that, we know that the body starts to decline.
This is usually when they’re getting jobs,
they’re getting married, having children,
but unfortunately, this is also a time when
a lot of people start developing those chronic
illnesses. Cognitively, they should be at
the adult level. Psychosocially, we have two stages
for the adult. We have the 19 to 34-year-olds
which are in intimacy versus isolation, and then
the 35 to 64-year-olds which are in generativity
versus stagnation. Now, we’re at the
older, and we’re clear
at the other end of the spectrum. So physically,
we start to decline. Cognitively, we start
to decline. We know that not everybody declines
to the extreme that some people do, but just
the nature of our bodies, we do start to decline.
And according to Erikson, we're at the ego
integrity versus despair. So let’s talk
a little bit about death.
That’s going to show up on the NCLEX too.
When do people understand exactly about
death? Now, we know adults. They understand
death, but kids, when do they understand it?
Well, infants and toddlers, they don’t know
anything about death. They don’t have any
concept of it. They don’t have any concept
in themselves or people around them. But they
always move on to preschoolers. That’s when
they start thinking magically. That’s when
they start thinking that maybe if somebody
is really sick or a loved one has died that
maybe it was their fault. They also believe
that the person is just sleeping.
So when you’re talking to children at this
age, it’s important to understand what they
think is going on. School-agers were starting
to get to the adult understanding, but again,
they are really curious about what’s going
on. And sometimes that can be kind of disturbing.
They can ask a lot of questions and parents
may think maybe they don’t care about the
loved one that has died, but it’s just their
normal trying to figure out what’s going
on with death. Adolescents now have the adult
version of death, but a lot of times, they
carry a lot of guilt. They think that maybe
they caused it, or something that they did,
maybe some of their risk taking or those kinds
of things. But they pretty much understand
what causes death and how death occurs and
what happens with death.
And then the older adult. Most older adults
know that death is part of life. It’s just
part of growing older. Most older adults have
accepted the fact that their time has come.
And so we’ve moved from infant to adult.
But again, it’s important to remember what
everybody believes that each stage about death.
So, we’re going to talk a little bit about
physical deviations. What happens when things
don’t go as we just said they should go?
Things like not rolling as an infant, you
need to start looking at physical things.
You know, is there a reason why they can’t
roll from their back to their front?
There should be a red flag for nurses.
Not transferring toys from hand to hand.
Is that a physical or is it a vision problem?
Not walking by 18 months, is that a physical
problem or a coordination problem or maybe
some neurological is going on. Not tripleing
birth weight. We worry a lot about organic
reasons and non-organic reasons. Do they have
failure to thrive? Are their parents not
feeding them? Not speaking, not speaking could
be from not being able to hear well, it could
be a neurological problem, or maybe it’s
an abuse or a neglect kind of problem where
nobody is working with the child.
Can’t follow simple commands, again, is that
a neurological problem where they can’t
put the words in the actions together? Bed
wetting in the childhood always makes us think
of either a problem with their bladder or
sexual abuse. So again, if they should have
been potty trained way before and they’re
still having bed wetting, the nurse needs
to have some red flags as to what’s going
on there. Absence of puberty by age 18,
obviously, that’s going to be a lot of self-esteem
kind of problems. But again, is there something
hormonal going on? Puberty at age seven the
other extreme, again, hormones is a big problem.
And then chronic illness, the earlier that
you develop a chronic illness, obviously,
the harder it’s going to be on that person
on their family and on their psychosocial
development. Cognitively again,
if they can’t follow
instructions, if they’re not interested
in playing with other children, red flag
should go up. Is it a behavioral problem?
Do they need psychological care? Or is it
an autism that maybe hasn’t gotten picked
up before because nobody noticed that they
weren’t wanting to play with other kids.
Anxiety about school. We see that a lot in
school age kids. Do they have stomach aches
every morning, headaches, because they’re
scared about school? Are they incapable of
understanding instructions? And then as we
move on to the older adult, dementia is a
big problem with the older adults and their
cognitive. If an older person starts showing
sides of dementia, it’s going to affect
the family, it’s going to affect their
physical care. So again, as the nurse is doing
their assessment picking up on those kinds
of things to be able to give them the social
help that they need. Psychosocial, now
we’re back to Erikson.
So what did all of those Erikson things mean
and what does the nurse need to look for?
Well, mistrust. In infant, it’s so sad
when an infant doesn’t trust the people
around them, and how do they get to that point?
They’re not yet in their needs met.
When you have a baby that’s crying and nobody
picks it up, a baby that doesn’t get fed,
all of a sudden that baby will stop crying.
It will stop trusting that anything is going
to happen to them. So as a nurse, you may
see that child come in with an illness and
you may think, “Why doesn’t that baby
cry? Why doesn’t that baby look at me when
I’m holding or when I’m feeding them?
You want to delve into that more to look for
that mistrust. Shame and doubt in
the toddler. If they’re
always told, “No, you can’t do that. No
you’re not doing that right. You didn’t
put your clothes on right. No, you can’t
do that. You can’t play ball that way.”
That starts to tell the toddler that they
can’t do anything right. And so then all
of the sudden, they just sit there. They quit.
They don’t do anything. So as a nurse, if
I’m trying to give a patient, the toddler
a block and say, “Come on, let’s play”
and they just lay it down and don’t do anything,
I’m going to start really watching and watching
that family bonding that’s going on. Guilt in the
preschooler, again, kind of goes
back to that “You can’t do anything right”
kind of thing. "You’re not dressing yourself.
Those clothes don’t match. You’re not very
good at that Pee Wee baseball." All of
those kinds of things start telling the child
that no matter what you do, you’re never
going to be good enough. And unfortunately,
if you go back to a lot of people that are
in jails and lots of people that are in trouble
with the law and you go back, and you can actually
go back to the very early ages on how they
were taken care of as children, how their
needs were met, the attention that they weren't
given. And so, these stages are really, really
important. Inferiority, again,
school is huge. We've hear
a lot about bullying, and that’s where this
comes in. If I don’t feel like I’m good
enough, if I don’t fit in, it causes a lot
of problems. Role confusion, once we get to
the teenager, again, teenagers are trying
to figure out who they are, where they fit
in, what their jobs should be. So if all of
those things that they don’t have people
to help them or they’re not able to cope
with the different decisions, they end up
choosing nothing. And unfortunately, these
are the kids that we see that are more involved
in drugs, or stay at home and just play video
games because they don’t see any point.
They don’t see a future for themselves.
And then isolation in the young adult.
This is very evident in our large divorce rate.
Adults that can’t commit, they don’t know
how to have a relationship, they’re very
egocentric, it’s all about them. So as they’re
moving on, if they can’t develop relationships,
they’re not going to be healthy. And then
stagnation. Once you get to be an adult and
you’ve had your family, if you don’t feel
like you’re going anywhere, if you’re
stuck in a dead-end job and you don’t know
how to advance yourself, you don’t know
how to go back to school, you just kind of
feel like you’re stuck, you go to work, maybe
you go home and you just sit and watch
TV, you’ve got to have a purpose. You’ve got
to have a reason for getting up, and that
kind of leads to the despair in the older
adult. There has to be a reason to get up
in the morning. So a lot of times, you
go into the hospitals
and you see older people that seemed very,
very depressed, or feel like, you know, “What’s
the difference if I take my medicine or not?”
You want to really delve into that and see
if they’re struggling with despair. Do they
have a purpose? This happens a lot of time
to people that have retired, and all of a
sudden, their whole reason for getting up
is gone. And so helping them get involved in hobbies
and volunteer work to give them a new renewal
into life. So that’s Erikson. So again, if
you haven’t figured out Erikson, you’re
going to want to do that before you take
the NCLEX exam.
So hospitalized patient. Now, you’re the
nurse in the hospital. So what does this all
mean when these patient shows up in the hospital?
So we start with infants. You know, infants need their
needs met. Infants need to be held in the
hospital or not. And we see that a lot in
the hospital if they’ve got IVs and oxygen.
Sometimes parents are afraid of holding them.
But again, we want to make sure that all their
needs are being met and that we have appropriate
toys that were keeping those infants safe
that parents aren’t propping bottles.
We have a lot of teachings to do with
And then moving on to toddlers. Now, we know
that they’re starting to walk. So not only
at home are we making it safe, but we got
to make the hospitals safe as well. We also
know that when a nurse walks in, hopefully,
the patient is scared because they do have
that stranger anxiety. If you have a toddler
that’s sitting there that doesn’t care
who comes in and out of the house, or out of
the room, or out of the treatment room, wherever
you are, that is a cause of concern because
they should be a little bit afraid of you.
But you should be able to win their confidence
over by playing with them.
Now, we move on to preschoolers. Now, they’d
want to know everything that you’re doing.
These are the kids that you’re going to
want to let them play with your stethoscope.
Let them look at the medicine. Play games
with them because they want to know, before
you do anything to them, what it is, they
want to understand. Preschoolers are also
really good having stuffed animals and doing
things to the stuffed animals so that they
know that it’s not going to hurt, or if
it is going to hurt. Being honest, but the
big reward being the prize box afterward,
you can win a lot of points to that way as
well. And then school age kids. Need
to be very honest
with school age kids, and make them start to
understand medical procedures, diseases, medicine.
And so they may not be able to understand
it at an adult level. And so when you’re trying
to reason with them, the reason they need
to take their medicine, you need to do it
at their level. But again, give them the benefit
of the doubt and help them to understand.
That’s what they want. They want to start
having some control.
And then teenagers. Their fear is loss of
control. So we give them as many choices as
we can. We also do a lot of teaching with
adolescents. They’re not just little kids,
but they’re also not adults. And so trying to
help them through, especially they’re working
with a chronic problem, maybe diabetes, that’s
going to affect the rest of their lives.
Helping them figure out where they fit in high school
and where they fit in college as far as how
am I going to do this. So there’s a lot of
teaching, but there’s also a lot of education
and helping them figure it out so that they
can make and form decisions about themselves.
And then adults. Adults in the hospital, a
lot of times, we just assume they’re adults.
They’ll do whatever they’re told. But
again, we’ve got to give them a reason.
There’s going to be a reason for doing what
they’re doing, and there has to be benefits,
and we need to give them all the information.
And then the older adults. Now we’re kind
of swinging the other way. Maybe they have
dementia and they don’t quite understand.
Maybe they’re hard of hearing and we need
to think about when we’re taking to them
to make sure that they understand. Or maybe
we’re starting to use technology. Like right
now in the hospital, a lot of older adults
still don’t do computers and those kinds
of things. And so when you walk in with your computer, they get
a little bit intimidated. So you need to orient them to that, let
them know that you’re still all about them
as a person and not all about technology.
So, we have a couple of review questions here,
and I’m just going to kind of buzz through
them because I want you to look through them
and I want you to try to figure out what the
answers are. You will have lots of practice
questions, and hopefully, you have an NCLEX
book where you can practice a lot of these
questions because the best way to know this
information besides studying is to take lots
So the first one, which behavior indicates
that an 18-month-old-infant, so we’re taking
of toddler, is developing none adaptive reaction
to hospitalization? So it’s kind of what we
just talked about, A, cries when mom leaves,
B, ignores mom when she arrives to the hospital,
C, is eating with their fingers instead of
spoon and fork, or D, is afraid of the dark?
So we’re talking about an 18-month-old. So the
big one that stands out to me is B, ignores
the mom when she comes back into the room.
Big red flag, if they don’t care when mom
and dad come back into the room, you need
to ask some questions.
Second question, you have an eight-month-old
infant sitting contently on mom’s lap.
You’re going in to start doing your well-baby check.
Which of the following should you do first?
Again, thinking about an eight-month-old,
thinking about the assessment that you need
to do. Should you A, measure the head circumference,
B, obtain body weight and height, C, auscultate
the heart and lung sounds, or D, check pupil
response to light? Hopefully, you picked C,
auscultate their heart and lung sounds. You
want to do that while they’re quiet. Some
of these other things doing to them is going
to make them cry. And so, you won’t get
a good assessment of their heart and lungs.
Third question, when obtaining a health history
from an older adult, the nurse must take which
characteristic of the older adult into consideration?
So what we just kind of talked about. A, the
older adult responds to pain sensation in
the same intensity as a younger patient. So
think about all those things you’ve learned
about pain. B, auditory acuity is the most
common sensory loss in the older adult population
and it may hinder the interview. C, the older
patient requires a lot of repetition because
their IQ declines. D, the older patient’s
response time in answering questions is just
as quick as that of a young person. So, if
you had to pick, what would you pick?
Hopefully, you picked B. We know that their
hearing isn’t so crisp as
it was before. So you need to make sure that they’re
understanding what you’re saying to them.
Four, in patients 65 years of age and older,
how is death commonly viewed? Now, this should
be an easy one. A, as a romanticized situation,
and I don’t know if that’s ever normal.
B, as a time of disassociation. C, as a part
of life. Or D, as a time of denial. Hopefully,
you picked C, it’s just the part of the
time of life. If they are at a time of denial,
again, that would be going against Erikson’s
despair, so you would want to look into that.
What would the nurse expect when exploring
a 9-year-old's concept of death? And again,
there will probably be depth questions on
there, so you want to make sure you know.
A, knows that death is a final process. B,
regards death as a temporary state of sleep.
C, believes death is something that just happens.
Or D, thinks death results from being bad.
So think back to your nine-year-old in school
age, and it’s A. It’s just the final process.
They’re starting get into that adult level
The last question. New parents are concerned
about unexpected characteristics of their
newborn baby. We know that new parents are
kind of on edge. They’re nervous. They want
to make sure everything is right. So it’s
really important that the nurse knows what’s
normal and what’s not normal. Which of the
following should cause the nurse to contact
the physician? So which one stands out as
being not right, A, swollen genitals, and
breast. B, high-pitched cry. C, misshapen
head. or D, Milia? Now, do you remember what
milia is? If you don’t, you want to make
sure you go back and look that up, but the
answer is B, a high-pitched cry, which usually
means a neurological problem.
So, we just went through developmental stages.
Again, know your Erikson, know your normal
growth and development from infant all the way to
adult, and you’ll do fine on the test. Good luck.