NCLEX-RN Growth and Development — Milestones and Developmental Theories

Normal aging changes affect every body system and influence care: (1) Vision: presbyopia (near vision decline starting ~40), cataracts, glaucoma risk, decreased adaptation to dark and glare; (2) Hearing: presbycusis (high-frequency hearing loss); (3) Cardiovascular: decreased cardiac output, increased BP variability, slower heart rate response to exercise; (4) Respiratory: decreased lung elasticity and reserve, decreased ciliary function (increased infection risk); (5) GI: decreased gastric acid (affecting iron, B12, calcium absorption), slower peristalsis (constipation risk), decreased appetite; (6) Renal: decreased GFR (drug dosing implications); (7) Musculoskeletal: decreased muscle mass (sarcopenia), decreased bone density (osteoporosis), joint changes, decreased flexibility; (8) Neurological: slower reaction time, decreased balance, mild changes in short-term memory normal (dementia is NOT normal aging); (9) Skin: thinning, decreased elasticity, slower wound healing, decreased sensation; (10) Immune: less robust response to infections and vaccines (immunosenescence); (11) Thermoregulation: less effective response to heat/cold; (12) Pharmacokinetics: changes in drug absorption, distribution, metabolism, excretion — most older adults need lower drug doses than younger adults. Polypharmacy is common and concerning. Nurses should distinguish normal aging from pathology — confusion, falls, weight loss, incontinence are not normal aging but signal medical issues. Beers Criteria identify potentially inappropriate medications in older adults.

Car seat recommendations (AAP and NHTSA): (1) Rear-Facing: as long as possible; until the child reaches the rear-facing seat's maximum height or weight limit (typically 40-50 pounds in convertible seats); minimum until age 2; rear-facing significantly reduces injury in crashes by 5x compared to forward-facing in young children; (2) Forward-Facing with Harness: when the child outgrows rear-facing limits; use until reaching the harness seat's maximum height or weight (often 65-80 pounds); (3) Belt-Positioning Booster: when the child outgrows the harness; use until the seat belt fits properly without the booster (typically 4'9' tall, age 8-12); (4) Seat Belt Alone: when the child can sit with back against the seat, knees bend at the seat edge, lap belt low across thighs, shoulder belt across chest (not neck), and stay this way for the entire ride. Back seat until age 13 — front airbags are dangerous to children. Booster seats are commonly skipped — they significantly reduce injury and should be used until belt fits properly. Properly used car seats can reduce death by 71% for infants and 54% for toddlers. Nurses in pediatric, emergency, and well-child settings should reinforce proper use; many hospitals have car seat clinics for installation checks.

Gestational Diabetes Mellitus (GDM) screening: standard one-step or two-step approach. Two-step (US standard): (1) Glucose Challenge Test (GCT) at 24-28 weeks: drink 50g glucose, check blood glucose 1 hour later; cutoff typically 130-140 mg/dL; if abnormal, proceed to confirmatory test; (2) 3-hour Glucose Tolerance Test (GTT): fasting; drink 100g glucose; check at 1, 2, 3 hours; GDM diagnosed if 2+ values exceed cutoffs (fasting 95, 1hr 180, 2hr 155, 3hr 140 mg/dL by Carpenter-Coustan criteria). Earlier screening (first trimester) for high-risk women: prior GDM, BMI ≥30, family history of T2DM, prior macrosomic baby, ethnic background with high T2DM rates (Hispanic, Black, Native American, Asian, Pacific Islander). Risks of untreated GDM: macrosomia (>4kg) with shoulder dystocia and birth trauma; neonatal hypoglycemia; respiratory distress; long-term: child increased obesity and diabetes risk; mother increased risk of T2DM (50% within 10 years). Management: nutrition therapy (consult dietitian, carb counting), exercise (after physician clearance), self-monitoring (4-7 times daily), insulin if diet/exercise inadequate (oral hypoglycemics increasingly used). Postpartum: 75g 2-hour OGTT at 6-12 weeks to identify those with persistent diabetes.

Sudden Infant Death Syndrome (SIDS) — sudden unexplained death of infants <1 year — was reduced by 50%+ through the AAP 'Back to Sleep' campaign (now 'Safe to Sleep'). Recommendations: (1) Supine (back) sleep position for every sleep until age 1 — significantly reduces SIDS risk; the position with strongest evidence; (2) Firm sleep surface — safety-approved crib mattress; no waterbeds, couches, soft surfaces; (3) Bare crib — no blankets, pillows, stuffed animals, bumpers, soft toys, sleep positioners; (4) Room-sharing but not bed-sharing — infant in separate sleep space in parents' room ideally for first 6-12 months; bed-sharing increases SIDS risk; (5) Avoid overheating — light clothing, room temperature 68-72°F; sleep sack instead of blanket; (6) Avoid prenatal smoke exposure and infant smoke exposure; (7) Breastfeed when possible — reduces SIDS risk; (8) Pacifier use at sleep times — reduces SIDS risk (after breastfeeding is established if breastfeeding); (9) Routine immunizations — reduce SIDS risk; (10) Avoid alcohol and drug exposure. Tummy time during awake/supervised periods (not for sleep) is important for development. Side sleeping is NOT a safe alternative — infants can roll to prone. Once infant can roll independently, they can be left in the position they assume but should be placed supine to start.

Live attenuated vaccines contain weakened pathogens that replicate in the body; while safe for healthy individuals, they can cause disease in vulnerable groups. Contraindications: (1) Pregnancy — defer live vaccines until after delivery; advise women to avoid pregnancy for 4 weeks after live vaccine; theoretical fetal risk, though no actual harm documented; (2) Severe immunocompromise: hematologic malignancy (leukemia, lymphoma) during chemotherapy or radiation; HIV with severe immunosuppression (specific CD4 thresholds); high-dose immunosuppressive therapy; recent organ transplant; primary immunodeficiency; (3) Anaphylaxis to vaccine components (gelatin, neomycin, egg protein for some vaccines); (4) Recent receipt of blood products may delay live vaccine response (defer 3+ months). Live vaccines: MMR, MMRV, Varicella, Zoster (Zostavax — older; Shingrix is non-live and preferred), Yellow Fever, Oral Typhoid, Rotavirus, Nasal Flu (LAIV — alternative), Smallpox/Monkeypox. Live vaccines can typically be given on the same day (or separated by ≥4 weeks). Inactivated vaccines (Tdap, HPV, hepatitis, injectable flu, pneumococcal, meningococcal) are safe in immunocompromised and pregnant individuals. Mild illness, antibiotic therapy, recent vaccine exposure are NOT contraindications. Family members of immunocompromised individuals can safely receive most live vaccines; the immunocompromised person should avoid contact with rotavirus diaper changes for 4 weeks.

Proper hand washing technique (CDC guidelines): (1) Wet hands with clean, running water (warm preferred for comfort and better lather); (2) Apply enough soap to cover all hand surfaces; (3) Scrub all surfaces for at least 20 seconds — palms, backs of hands, between fingers, under nails, including wrists; the 20 seconds typically equals 'Happy Birthday' sung twice; (4) Rinse thoroughly under running water; (5) Dry hands with a clean paper towel or air dryer; (6) Use the paper towel to turn off the faucet (avoiding recontamination); (7) Use the paper towel to open the bathroom door if applicable. Alcohol-based hand sanitizer (60%+ alcohol) is acceptable when soap and water are unavailable, BUT NOT effective for: visibly soiled hands; certain pathogens (C. difficile, Cryptosporidium, norovirus to lesser extent); after bathroom use (soap and water preferred). When to use alcohol sanitizer: apply enough to cover all surfaces; rub until dry (typically 20 seconds). Reasons hand hygiene fails: (1) Too brief — most people wash <10 seconds; (2) Inadequate technique — missing thumbs, fingertips, wrists; (3) Recontamination — touching faucet, dispenser, door without paper towel; (4) Not done at the right times. Healthcare workers should perform hand hygiene at minimum 5 'moments' (WHO): before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, after contact with patient surroundings.

Exercise initiation guidance for previously sedentary clients: (1) Medical clearance — recommended for adults 45+ starting vigorous exercise, those with chronic conditions, or those with cardiovascular risk factors; ECG stress test for some; (2) Start gradually — '10% rule' for runners (don't increase weekly mileage by more than 10%); applies generally to intensity, frequency, duration; (3) Warm up — 5-10 minutes of low-intensity activity to raise heart rate, increase blood flow to muscles; (4) Cool down — 5-10 minutes of decreasing intensity; stretching during cool-down; (5) FITT principle for prescription: Frequency (how often), Intensity (how hard), Time (how long), Type (what kind); (6) Variety — combine aerobic (walking, swimming, cycling), strength (resistance training 2+ days/week), flexibility (stretching, yoga), balance (especially for older adults); (7) Hydration — water before, during, and after exercise; (8) Nutrition — adequate fuel and recovery foods; (9) Equipment — proper shoes, supportive clothing, helmets and safety gear; (10) Listen to the body — distinguish discomfort (normal) from sharp pain (stop); rest days important; (11) Signs to stop exercise: chest pain, severe shortness of breath, dizziness, irregular heartbeat, severe joint pain. Realistic goal-setting: 150 minutes moderate or 75 minutes vigorous aerobic exercise per week, plus strength training 2x/week — but starting with any activity is beneficial. Enjoyable activities promote adherence. Tracking progress motivates continuation.

Diabetes self-management education is comprehensive and ongoing. Core teaching: (1) Disease overview — type 2 diabetes is insulin resistance plus relative insulin deficiency; can be progressive but well-managed; (2) Blood glucose monitoring — proper meter use, when to check (fasting, before meals, 2 hours after meals, bedtime — depending on regimen), recording, target ranges (typically fasting <130, post-prandial <180, A1C <7%); (3) Hypoglycemia — symptoms (shakiness, sweating, hunger, confusion), Rule of 15 (15g fast carb, recheck in 15 min, repeat if needed, then complex carb), prevention; (4) Hyperglycemia — symptoms (polyuria, polydipsia, fatigue, blurred vision), when to call (consistently >300, ketones, unable to keep fluids down), DKA/HHS warning signs; (5) Medications — names, doses, timing, side effects, sick day rules (continue insulin, may need to hold metformin); (6) Nutrition — carb counting, balanced meals, portion control, consistent meal timing, alcohol effects, sugar substitutes; (7) Exercise — benefits, blood glucose effects, hypoglycemia prevention during exercise; (8) Foot care — daily inspection, moisturizing (not between toes), nail care, professional pedicures avoid, proper footwear, never barefoot, immediate attention to wounds; (9) Skin care — overall hygiene, treat infections promptly; (10) Eye care — annual dilated exam; (11) Dental care — twice yearly visits; diabetes affects gum health; (12) Travel preparation; (13) Identification — medical alert jewelry or wallet card; (14) Pregnancy planning if applicable; (15) Sick day management; (16) Mental health — diabetes burden, depression screening. Group classes, diabetes educators, ongoing dietitian visits support success.

Neonatal jaundice (hyperbilirubinemia) is common — 60% of full-term and 80% of preterm infants develop visible jaundice. Most cases are physiologic and benign. Pathologic jaundice (warrants evaluation): (1) Onset in first 24 hours of life — suggests hemolysis, sepsis, or other serious cause; (2) Rapidly rising bilirubin (>5 mg/dL/day); (3) Total bilirubin >15 mg/dL in full-term infants (>10 in preterm); (4) Jaundice persisting >2 weeks in full-term, >3 weeks in preterm; (5) Direct (conjugated) bilirubin >2 mg/dL — suggests biliary obstruction or hepatocellular disease; (6) Associated signs: poor feeding, lethargy, irritability, hypotonia, fever, vomiting; (7) Family history of jaundice. Severe untreated jaundice can cause kernicterus — irreversible neurological damage from bilirubin crossing into the brain. Risk factors: prematurity, breastfeeding (more common but typically benign), ABO or Rh incompatibility, hereditary hemolytic disorders (G6PD deficiency, sickle cell), birth trauma with bruising. Assessment: visual inspection (jaundice typically progresses cephalocaudal); serum bilirubin levels; transcutaneous bilirubinometer for screening. Treatment: phototherapy (specific wavelength of light converts bilirubin to excretable form) for moderate levels; exchange transfusion for very high levels or signs of kernicterus. Breastfeeding jaundice: continue breastfeeding, ensure adequate intake. Discharge teaching: parents should observe for worsening jaundice and seek evaluation if concerning.

Breast cancer screening guidelines vary by organization but generally include: (1) Average-risk women: USPSTF 2024 update recommends biennial screening mammograms starting at age 40 (lowered from 50 in 2024 update); ACS recommends annual screening starting at 45, with option to start at 40, then biennial after 54; ACR recommends annual starting at 40. (2) Higher-risk women (family history, prior breast cancer, BRCA mutations, chest radiation): earlier screening, MRI in addition to mammography. (3) Stopping: USPSTF says insufficient evidence after 75; many recommendations consider life expectancy. Clinical Breast Exam (CBE): performed by clinicians during physicals; effectiveness debated; ACS removed routine CBE recommendation in 2015. Breast self-exam (BSE) — historically taught as routine practice, but evidence does not support reducing mortality; current recommendation is 'breast awareness' — knowing what is normal and reporting changes (lumps, dimpling, nipple discharge, skin changes). Concerns about mammography: false positives (additional imaging, biopsies, anxiety); overdiagnosis (detecting cancers that would not have become symptomatic); radiation exposure (very low dose). Benefits: reduced breast cancer mortality; earlier detection allows less aggressive treatment. The trade-offs and individual risk profile inform screening decisions. Shared decision-making between provider and patient is increasingly emphasized. Nurses help patients understand screening options and address barriers.