MATERNAL AND CHILD HEALTH NURSING (8th Edition) - 1-3732-1820-1867

31
Nursing Care of a Family With a

Preschool Child
Cathy Edwards is a 3-year-old you meet at a health maintenance visit. Her father
cares for her at present because her mother is hospitalized with preterm labor for a
second pregnancy. Her father tells you he is concerned because Cathy talks
constantly with an imaginary friend named Emma. She makes up stories about
events that can’t possibly be true. When corrected, Cathy stutters so badly no one
can understand her. Her father is also concerned because his daughter cries when
he leaves her at daycare.
The previous chapter described toddler growth and development and the
abilities children develop during that period. This chapter adds information about
the changes, both physical and psychosocial, that occur during the preschool years.
Such information builds a base for care and health teaching for this age group.
Is Cathy’s father describing typical preschool behavior, or does Cathy need a

referral to a child care specialist?
KEY TER MS
broken fluency
bruxism
conservation
ectomorphic body build
egocentrism
Electra complex
endomorphic body build
genu valgus
intuitional thought
Oedipus complex
secondary stuttering
OBJ EC TIV ES
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After mastering the contents of this chapter, you should be able to:
1. Describe normal growth and development as well as common parental concerns of
the preschool period.
2. Identify 2020 National Health Goals related to the preschool period that nurses can
help the nation achieve.
3. Assess a preschooler for normal growth and developmental milestones.
4. Formulate nursing diagnoses related to preschool growth and development or
common parental concerns.
5. Identify expected outcomes for nursing care of a preschooler as well as help parents
manage seamless transitions across differing healthcare settings.
6. Using the nursing process, plan nursing care that includes the six competencies of
Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork
& Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI),
Safety, and Informatics.
7. Implement nursing care related to normal growth and development of a
preschooler, such as preparing a preschooler for an invasive procedure.
8. Evaluate expected outcomes for achievement and effectiveness of care.
9. Integrate knowledge of preschool growth and development with the interplay of
nursing process, the six competencies of QSEN, and Family Nursing to promote
quality maternal and child health nursing care.
The preschool period traditionally includes the years 3, 4, and 5. Although physical
growth slows considerably during this period, personality and cognitive growth
continue at a rapid rate. Therefore, this is also an important period of growth for parents
because they may be unsure how much independence and responsibility for self-care
they should allow their rapidly maturing child. Most children of this age want to do
things for themselves—choose their own clothing and dress themselves, feed
themselves independently, wash their own hair, and so forth. As a result, parents of a
preschooler may find their child dressed in one red and one green sock, going to
preschool with unwashed ears, or trying to eat soup with a fork. They need reassurance
that this behavior is typical because it is the way children explore and learn about new
experiences (Fergusson, Boden, & Horwood, 2013).
Parents may also need some guidance in separating those tasks that a preschooler
can accomplish independently from those that still require some adult supervision so
they can set sensible limits. Setting limits protects children from harming themselves or
others while participating in all the interesting experiences available to them. Box 31.1
lists 2020 National Health Goals related to this in-between toddler and school-age
period.
BOX 31.1
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Nursing Care Planning Based on 2020 National Health Goals
A number of 2020 National Health Goals are designed to target the preschool
population. They include:
• Increase the number of states and the District of Columbia with laws requiring
helmets for bicycle riders under 15 years of age, from 19 states to 27 states.
• Decrease acute middle ear infections (otitis media) among children from 246 out
of 1,000 to 221 out of 1,000.
• Increase the proportion of children aged 19 to 35 months who receive the
recommended doses of diphtheria, tetanus, and pertussis (DTaP); polio; MMR;
Haemophilus influenzae type B (HiB); hepatitis B; varicella; and PCVs from
44.3% to 90%.
• Increase the rate of use of forward-facing child car seats among children age 1 to 3
years from a baseline of 72% to 79%.
• Reduce the proportion of children 3 to 11 years exposed to secondhand smoke
from 52.2% to 47% (U.S. Department of Health and Human Services, 2010; see
www.healthypeople.gov).
Nurses can help the nation achieve these goals by alerting parents to these concerns
as well as by serving as consultants at child care and preschool settings to be certain
that preschoolers are protected against secondhand smoke, that recommended
automobile restraints are used, and that children are fitted with helmets before
beginning bicycle riding.
Nursing Process Overview

FOR HEALTHY DEVELOPMENT OF A PRESCHOOLER
ASSESSMENT
Regular assessment of a preschooler includes obtaining a health history and
performing both a physical and developmental evaluation at healthcare visits.
Preschoolers may speak very little during a health assessment; they may even revert
to baby talk or infantile actions such as thumb-sucking if they find a health visit
stressful. A history that details their usual performance level is therefore important
for accurate evaluation.
Assess a child’s weight, height, and body mass index (BMI) according to standard
growth charts (available at http://thePoint.lww.com/Flagg8e). Keep in mind that these
charts are based on average weights and heights of white American children, so
children from other racial backgrounds may not completely conform with these
norms (i.e., they may fall into the lower or upper percentiles). Also assess a child for
general appearance. Does the child appear alert? Happy? Active? Preschoolers
typically have 6 to 12 respiratory infections per year; therefore, many of them will
have one at the time of a health assessment.
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NURSING DIAGNOSIS
Nursing diagnoses for preschoolers typically center on health promotion or
unintentional injury prevention. Examples include:
Health-seeking behaviors related to developmental expectations
Risk for injury related to increased independence outside the home
Delayed growth and development related to frequent illness
Risk for imbalanced nutrition, more than body requirements, related to fast food
choices
Risk for poisoning related to maturational age of the child
Parental anxiety related to lack of understanding of childhood development
OUTCOME IDENTIFICATION AND PLANNING
For many parents, preschool is a difficult time because a child is at an in-between
stage—no longer an infant, although not yet ready for formal school. Planning and
establishing expected outcomes for care of children at this age often begin with
establishing a schedule for discussing normal preschool development with the
parents. Planning for unintentional injury prevention such as how to cross streets
safely becomes increasingly critical as children begin to enjoy experiences away from
home. It is also important to plan opportunities for adventurous activities and
interaction with other children. Parents may find it helpful to be referred to online
resources for further information (see Chapter 28).
IMPLEMENTATION
Preschool children imitate moods as well as actions. An important nursing
intervention, therefore, is role-playing a mood or attitude you would like a child to
learn. To project an attitude that a health assessment is an enjoyable activity, you
might suggest preschoolers participate by listening to their heart or coloring the table
paper. Unintentional injury prevention is also best taught by role modeling (e.g., a
parent always crosses streets at the corner, a parent doesn’t start the car until seatbelts
are in place).
OUTCOME EVALUATION
An evaluation of expected outcomes needs to be continuous and frequent. Because
growth during this period is more cognitive and emotional than physical, parents may
report little growth. Evaluating specific areas can help them appreciate that progress
has occurred. Examples of expected outcomes might include:
Child states importance of holding parent’s hand while crossing streets.
Parent states realistic expectations of 3-year-old child’s motor ability by next
visit.
Mother reports she has prepared her 4-year-old for new baby by next visit.
Nursing Assessment of a Preschooler’s Growth and
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Development
An assessment of preschoolers needs to include physical, cognitive, and developmental
growth (Box 31.2).
BOX 31.2
Nursing Care Planning Using Assessment
APPEARANCE OF THE AVERAGE PRESCHOOLER
PHYSICAL GROWTH
A definite change in body contour occurs during the preschool years. The wide-legged
gait, prominent lordosis, and protuberant abdomen of the toddler change to slimmer,
taller, and much more childlike proportions. Contour changes are so definite that future
body type—ectomorphic body build (slim body build) or endomorphic body build
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(large body build)—becomes apparent. Handedness also begins to be obvious. A major
step forward is a child’s ability to learn extended language, which is achieved not only
by motor development but also by cognitive development. Children of this age who are
exposed to more than one language or who live in a bilingual family have a unique
opportunity to master two languages with relative ease because of this increased
cognitive ability.
Lymphatic tissue begins to increase in size, particularly the tonsils; levels of
immune globulin (Ig)G and IgA antibodies increase. These changes tend to make
preschool illnesses more localized (e.g., an upper respiratory infection remains localized
to the nose with little systemic fever).
Physiologic splitting of heart sounds may be present for the first time on
auscultation; innocent heart murmurs may also be heard for the first time. This type of
murmur occurs because of the changing size of the heart in reference to the thorax
because the anteroposterior and transverse diameters of the chest have not yet reached
adult proportions. Pulse rate decreases to about 85 beats/min, and blood pressure holds
at about 100/60 mmHg.
The bladder is easily palpable above the symphysis pubis; voiding is frequent
enough (9 or 10 times a day) that play must be interrupted, and voiding accidents may
occur if a child becomes absorbed in an activity.
A child who earlier in life had an indeterminate longitudinal arch in the foot
generally demonstrates a well-formed arch now. Muscles are noticeably stronger, so
activities such as gymnastics become possible. Many children at the beginning of the
period exhibit genu valgus (knock-knees); this disappears with increased skeletal
growth at the end of the preschool period.
Weight, Height, Body Mass Index, and Head Circumference

Weight gain is slight during the preschool years; the average child gains only about 4.5
lb (2 kg) a year. During these years, appetite remains the same as it was during the
toddler years, a level perhaps considerably less than some parents would like or expect.
Height gain is also minimal during this period: only 2 to 3.5 in. (6 to 8 cm) a year on
average. Head circumference is not routinely measured at physical assessments on
children over 2 years of age because it changes little after this time.
Teeth
Children generally have all 20 of their deciduous teeth by 3 years of age; permanent
teeth don’t replace these until school age. Preserving these teeth is important because
they hold the position for the permanent teeth as the child’s jaw grows larger. If a
deciduous tooth has to be removed, children need conscientious follow-up to be certain
a space for a permanent tooth remains (de Amorim Lde, Estrela, & da Costa, 2011).
DEVELOPMENTAL MILESTONES
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Each year during the preschool period marks a major step forward in gross motor, fine
motor, and language development. Play activities change focus dramatically as the
preschooler learns new skills and understands more about the world (Fig. 31.1). Table
31.1 summarizes major milestones of the period.
Figure 31.1 Preschoolers like to imitate the roles of adults as they

learn about the world around them.
TABLE 31.1 SUMMARY OF PRESCHOOL GROWTH AND DEVELOPMENT

Fine Motor Gross Motor
Age (in Years) Skills Skills Language Play
3 Undresses self; Runs; alternates Vocabulary of Able to take
stacks tower feet on stairs; 900 words turns; very
of blocks; rides tricycle; imaginative
draws a cross stands on one
foot
4 Can do simple Constantly in Vocabulary of Pretending is
buttons motion; 1,500 words major activity
jumps; skips
5 Can draw a six- Throws Vocabulary of Likes games
part figure; overhand 2,100 words with numbers
can lace shoes or letters
Language Development
The extent of a 3-year-old child’s vocabulary varies depending on how much the child
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has been encouraged to ask questions or participate in conversations (Box 31.3). A child
typically, however, has a vocabulary of about 900 words and uses it to ask questions
constantly, up to 400 a day, such as “Why is snow cold?” “How do worms hear?” and
“What does your tongue do?” A child needs simple answers to such questions to
encourage curiosity, vocabulary building, and questioning. Words that sound alike but
mean different things such as “whether” and “weather” can be confounding to children
of this age. If a parent tells a child her shoes should go on with the buckles on the
outside, she may seem to understand but return in a few minutes to ask, “Why do I have
to go outside to put on my shoes?”
BOX 31.3
Nursing Care Planning to Respect Cultural Diversity
Whether children are allowed to ask questions is culturally determined and can make
a difference in how much vocabulary a child uses. In a society in which children are
expected to be seen and not heard, a preschool child may not have the same
expressive vocabulary as a child who has been encouraged to ask questions.
Recognition that differences among cultures can affect levels of development means
assessments must be individualized and meaningful in terms of the cultural milieu.
Egocentrism, or perceiving that one’s thoughts and needs are better or more important
than those of others, is also strong during the preschool period. Preschoolers cannot
believe that not everyone knows facts they know; if asked, “What is your name?” they
may reply, “Don’t you know it?” As a part of egocentrism, preschoolers define objects
mainly in relation to themselves, so a spoon is “what I eat with,” not a curved metal
object; a crayon is “what I write with,” not an orange wax object.
Four- and 5-year-old children enjoy participating in mealtime conversation and can
describe an incident from their day in great detail. Remember that preschoolers tend to
imitate language exactly, so if they hear less-than-perfect language, this is the language
pattern they adopt. They may imitate and use “bathroom language” because of the
attention from adults this generates.
Preschoolers are egocentric, so they define objects in relation to themselves (e.g., a
key is not a metal object but “what I use to open a door,” a car is not a means of
transportation but “what Mom uses to take me to school”).
Play
Preschoolers do not need many toys because, with an imagination keener than it will be
at any other time in life, they enjoy games that use imitation such as pretending they are
a teacher, cowboy or cowgirl, firefighter, or store clerk. Many preschoolers have
imaginary friends at this stage (Nielsen, 2012), which often exist until children formally
begin school.
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Four- and 5-year-olds divide their time between roughhousing and imitative play.
Five-year-olds become interested in group games or reciting songs they have learned in
kindergarten or preschool.
QSEN Checkpoint Question 31.1

INFORMATICS
Cathy, who is 3 years old, constantly asks questions. When teaching her father about
communication skills in children of this age, the nurse should state that a child of
Cathy’s age typically asks how many questions in a day?
a. Around 50
b. 100 to 200
c. 300 to 400
d. 600 or more
Look in Appendix A for the best answer and rationale.
EMOTIONAL DEVELOPMENT
Children change a great deal in their ability to understand their world and how they
relate to other people during the preschool years.
Initiative
The developmental task for the preschool-age child is to achieve a sense of initiative
versus guilt (Erikson, 1993). Children with a well-developed sense of initiative like to
explore because they have discovered that learning new things is fun.
If children are criticized or punished for attempts at initiative, they can develop a
sense of guilt for wanting to try new activities or to have new experiences. Those who
leave the preschool period with a sense of guilt can carry it with them into school
situations. They may even have difficulty later in life making decisions about
everything from changing jobs to choosing an apartment because they cannot envision
that they are capable of solving the associated problems that will come with change.
To gain a sense of initiative, preschoolers need exposure to a wide variety of
experiences and play materials so they can learn as much about how things work as
possible. They are ready to explore outside their homes such as enjoying a trip to the
zoo or an amusement park (Fig. 31.2). They enjoy going with their family on vacation.
These types of experiences lead to increased vocabulary (e.g., at the zoo, words such as
giraffe, elephant, and bear come alive because they are transferred from abstract
concepts to the actual animals).
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Figure 31.2 Preschoolers like exposure to new events and places.
Here, a 3-year-old child is eager to explore the woods during a hike
with the family.
Urge parents to provide play materials that encourage creative play, such as finger
paints, soapy water to splash or blow into bubbles, sand to build castles, and modeling
clay or homemade dough to mold into figures or make into pretend cookies. These are
messy activities, so some parents prefer not to allow a child to indulge in them more
than once a week, but any experience with free-form play is helpful.
Preschoolers tend to have such active imaginations that they need little guidance in
this type of play. They smear both hands into clay or finger paint and create
instinctively. What they make may not be recognizable; it is the enjoyment of feeling
the material and how they can manipulate it that captures the experience.
Imitation
Imitating the actions of the people around them peaks during preschool age. Role
modeling this way should be fun and does not have to be accurate. If a child is
pretending to be a police officer who is busy putting out fires or a firefighter who is
stopping playmates from speeding, the fact that the child is freely imitating a role is
more important than getting the role absolutely correct. If a parent is concerned that a
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child should recognize these roles more accurately, it is usually best to suggest that the
parent not to stop the play but rather to explain where firefighters work and that their
job is to put out fires the next time they drive past the fire station.
Children generally imitate those activities best that they see their parents performing
at home. A young girl will set the table for breakfast, eat with her “spouse,” help clean
off the table, and leave for work. A young boy might work on his computer, pretend to
feed a doll, and put the doll to bed as he has seen his father do with a younger sibling. In
addition to learning what activities adults carry out at home, preschoolers should also be
introduced to their parents’ work environments. Such visits not only provide a visual
context for the parent’s job but also let a child learn such words as photocopier,
assembly line, legal brief, or fax machine.
Fantasy
Toddlers cannot differentiate between fantasy and reality; they believe cartoon
characters they see on television are real. Preschoolers, however, begin to make this
differentiation. They may become so engrossed in a fantasy role that they fear they are
“stuck” in the fantasy and are no longer themselves. Such intense involvement in play is
part of “magical thinking,” which is active at this age (i.e., believing thoughts and
wishes can come true).
Parents sometimes strengthen this feeling without realizing it, so they (and you)
need to be careful in this regard. A preschooler, like Cathy for example, whom you care
for in the hospital might be pretending she is a white rabbit. When you walk into her
room, you are aware of the game, so you might say, “That’s strange; I don’t see Cathy
anywhere. All I see is a white rabbit.” Cathy may be frightened that she has actually
become a white rabbit; how will she ever get home again? A better response from you
would be to support the imitation—this is age-appropriate behavior and a good way to
explore roles—by saying instead, “What a nice white rabbit you’re pretending to be.”
This both supports the fantasy and yet reassures the child she is still herself.
Oedipus and Electra Complexes

Although the development of Oedipus and Electra complexes may have been overstated
by Freud—possibly because of gender bias—many children do seem to manifest such
behavior (Erreich, 2011). An Oedipus complex refers to the strong emotional
attachment a preschool boy demonstrates toward his mother; an Electra complex is the
attachment of a preschool girl to her father. A daughter demonstrating this complex
might prefer to always sit beside her father at the table, or she may ask for her father to
tuck her in at night. She makes a point that she is “Daddy’s girl.” A mother who is not
prepared for this behavior may feel hurt and cut off from family interaction. A father
may feel the same way when his son wants to sit beside his mother and prefers her to be
the one to tuck him in for the night.
Parents can be assured this phenomenon of competition and romance in
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preschoolers is a normal part of maturing. Some parents may need help in handling
feelings of jealousy and anger, however, particularly if a child is vocal in expressing
feelings toward a parent.
Gender Roles
Preschoolers begin to be aware of the difference between sexes and so need to be
introduced to both gender roles. Encourage single parents to plan opportunities for their
children to spend some time with adults other than themselves, such as a grandparent, a
friend, or a relative of the opposite sex, for this experience. If a child is hospitalized
during the preschool period, a nurse could readily fill this role.
Many parents do not want their child to grow up as they did, with a fixed gender
role as a result of stereotyping. Help them understand that parents reinforce such
attitudes by their actions as well as by their words. For example, a father may tell his
son it is important for both boys and girls to do housework, but if the father never does
dishes, he is teaching his son that managing a household is not a man’s job.
Socialization
Because 3-year-olds are capable of sharing, they play with other children their age much
more agreeably than do toddlers, which makes the preschool period a sensitive and
critical time for socialization. Preschoolers who are exposed to other playmates have an
easier time learning to relate to people than those raised in an environment where they
rarely see other children of the same age (Paulus & Moore, 2012) (Fig. 31.3).
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Figure 31.3 The preschool child moves past parallel play to make new
friendships.
Although 4-year-olds continue to enjoy play groups, they may become involved in
arguments more than they did at 3 years of age, especially as they become more certain
of their role in the group. This development, like so many others, may make parents
worry that a child is regressing. However, it is really forward movement that involves
some testing and identification of their group role.
Five-year-olds begin to develop “best” friendships, perhaps on the basis of who they
walk to school with or who lives closest to them. The elementary rule that an odd
number of children will have difficulty playing well together generally pertains to
children at this age: two or four will play, but three or five will quarrel.
Cognitive Development
According to Piaget (1969), cognitive development is still preoperational by 3 years of
age, although children during this period also enter a second phase called intuitional
thought. During this second phase of development, children learn by asking questions
such as “How come?” and “Why?” Piaget named this stage “intuitive thought” because
he believed that children tend to be so certain of their knowledge and understanding that
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they are unaware of how they gained this knowledge initially. Children in the intuitive
substage may still demonstrate many advances in cognitive skills. They may shift from
using only magical beliefs to using rational beliefs to explain situations or events that
they had not experienced previously. Very young children may explain that a new
building “grew out of the ground,” whereas older children understand it was built.
Intuitive children show a style of thinking he called “centration.” These children
typically are focused on the characteristic of an object or person, and they base their
decisions or judgment on that one characteristic (as opposed to considering multiple
characteristics). For example, a 4-year-old who was asked to put toys into groups might
focus his or her attention on the color of the toy instead of the shape or the material
from which they are constructed. Centration also means that preschoolers cannot make
mental substitutions and often feel they are always right. It’s important to remember this
when explaining procedures to preschoolers. They cannot see your side of the situation,
they cannot hurry because you must have something done by 10 o’clock, and they
cannot hold still just because you want them to.
Preschoolers are not yet aware of the property of conservation. This means that if
they have two balls of clay of equal size, but one is squashed flatter and wider than the
other, they will insist the flatter one is bigger (because it is wider) or the intact one is
bigger (because it is taller). They cannot see that only the form, not the amount, has
changed. This inability to appreciate conservation has implications for nursing care
because it means preschoolers are not able to comprehend that a procedure performed
two separate ways is the same procedure. If the nurse before you, for example, told a
child to turn on his right side and then his left side while his bed was made, you may
have to allow him to turn those same ways or he will insist you are making his bed
wrong. Decentering, combined with the concept of conservation, appear prior to more
sophisticated logical thinking abilities.
Moral and Spiritual Development

Children of preschool age determine right from wrong based on their parents’ rules
because they have little understanding of the rationale for these rules or even whether
the rules are consistent. If asked the question, “Why is it wrong to hit other children?”
the average preschooler answers, “Because my mother says so.” Because preschoolers
depend on their parents to supply rules for them, when faced with a new situation, they
may have difficulty understanding the rules they know also apply to the new situation
such as a hospital.
Preschoolers begin to have an elemental concept of spirituality if they have been
provided some form of religious training. Belief in an outside force aids in the
development of conscience; however, preschoolers tend to do good out of self-interest
rather than because of strong spiritual motivation (Kohlberg, 1984). Children at this age
enjoy the security of religious holidays and religious rituals such as prayer before meals
because these rituals offer them the same reassurance and security as a familiar nursery
rhyme read over and over.
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What If . . . 31.1
Cathy, 3 years old, understands the rule “Don’t steal from a store.” Would
she also understand “Don’t steal from a hospital”?
Planning and Implementation for the Health Promotion of

a Preschooler and Family
Preschoolers are old enough to begin to take responsibility for their own actions.
Children’s safety, nutritional health, daily activities, and family functioning are all
affected by this increased responsibility.
PROMOTING PRESCHOOLER SAFETY

As preschoolers broaden their horizons, safety issues must also widen. By age 4 years,
children may project an attitude of independence and the ability to take care of their
own needs. However, they still need supervision to be certain they do not injure
themselves or other children while roughhousing and to ensure they do not stray too far
from home. Their interest in learning adult roles may lead them to exploring the blades
of a lawn mower or an electric saw or a neighbor’s pool (Bowman, Aitken, Robbins, et
al., 2012). Because they imitate adult roles so well, they may imitate taking medicine if
they see family members doing so. It’s also not too early to think about gun safety or
being certain any gun in their home is locked away separate from its ammunition
(Senger, Keijzer, Smith, et al., 2011).
A final area to consider is automobile safety. Preschoolers must be reminded
repeatedly to buckle their booster seat and not to walk in back of or in front of
automobiles. Otherwise, a preschooler’s thought “I want to play with Mary across the
street” can be so quick and so intense that the child will run into the middle of the street
before remembering street safety rules. Additional safety points for the preschool period
are summarized in Box 31.4.
BOX 31.4
Nursing Care Planning to Empower a Family
COMMON SAFETY MEASURES TO PREVENT UNINTENTIONAL

INJURIES TO PRESCHOOLERS
Q. Cathy’s father says to you, “My preschooler is so active! How can I keep her
safe?”
A. All of the safety measures that apply to toddlers also apply to preschoolers. In
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addition, try these tips:
Possible Unintentional
Injury Prevention Measure
Motor vehicles Teach safety with tricycles (e.g., look before crossing
driveways, do not cross streets).
Teach the child to always hold hands with an adult before
crossing a street.
Teach parking lot safety (e.g., hold hands with an adult, do
not run behind cars that could be backing up).
Teach children to consistently wear helmets when beginning
bicycle riding.
Falls Always supervise a preschooler at a playground.
Remove drawstrings from hooded clothing.
Help the child to judge safe distances for jumping or safe
heights for climbing.
Drowning Teach beginning swimming.
Animal bites Do not allow the child to approach strange dogs.
Supervise the child’s play with family pets.
Poisoning Never present medication as a candy.
Never take medication in front of a child.
Never store food or substances in containers other than their
own.
Post the telephone number of the poison control center by
the telephone or as a cell phone contact number (1-800-
222-1222).
Teach the child that medications are a serious substance and
not for play.
Burns Store matches in closed containers.
Do not allow the preschooler to help light birthday candles
or fireplaces; fire is not fun or a treat.
Community safety Teach the preschooler that not all people are friends (e.g.,
“Do not talk to strangers or take candy from strangers”).
Define a stranger as someone the child does not know, not
someone odd looking.
Teach the child to say “no” to people whose touching he or
she does not enjoy, including family members. (When a
child is sexually maltreated, the offender is usually a
family member or close family friend.)
General Know the whereabouts of the preschooler at all times.
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Be aware the frequency of unintentional injuries increases
when parents are under stress. Special precautions must be
taken at these times.
Some children are more active, curious, and impulsive and
therefore more vulnerable to unintentional injuries than
others.
Keeping Children Safe, Strong, and Free

The preschool years are not too early a time to educate children about the potential
threat of harm from strangers or how to address bullying behavior (from children or
adults) at preschool or at play (Jonson-Reid, Kohl, & Drake, 2012) through such
measures as:
• Cautioning a child never to talk with or accept a ride from a stranger
• Teaching a child how to call for help in an emergency (yelling or running to a
designated neighbor’s house if outside, or dialing 911 if near a phone)
• Describing what police officers look like and explaining that police can help in
an emergency situation
• Explaining that if children or adults ask them to keep secrets about anything that
has made them uncomfortable, they should tell their parents or another trusted
adult, even if they have promised to keep the secret
• Explaining that bullying behavior from other children is not to be tolerated and
should be reported so they can receive help managing it
It is often difficult for parents to impart this type of information to preschoolers
because they don’t want to terrify their child about the world. They also can’t imagine
their child will ever be in a situation in which the information will be needed. If the
information is presented in a calm and everyday manner, however, children can use it to
begin to build safe habits that will help them later when they are old enough to walk
home from school alone or play with their friends unsupervised.
Motor Vehicle and Bicycle Safety

Because of front seat airbags, preschoolers need to be buckled into car seats or booster
seats in the back seat (American Academy of Pediatrics, 2012). Urge parents to stress
the important role of seat belts in preventing injury and to make a rule that the car does
not move until seat belts are fastened. Many preschoolers outgrow their car seats during
this period (when they reach about 40 lb) and need to graduate to a booster-type seat.
Remind parents to check the position of the shoulder harness in both types of seat so the
belt doesn’t cross a child’s face or throat.
Preschool is also the right age to promote bicycle safety because falls off bicycles
are a major cause of severe head injuries in this age group (Agarwal & Pruthi, 2010). To
prevent such injuries, preschoolers need a safety helmet approved for children their age
and size. Encourage parents who ride bicycles to demonstrate safe riding habits by
1836
wearing helmets as well. Seeing a parent routinely wearing a helmet may well be the
most compelling reason for a preschooler to wear one.
What If . . . 31.2
Cathy tells the nurse she knows to not leave preschool with anyone who is
strange. Is that the same as knowing not to leave with a stranger?
PROMOTING THE NUTRITIONAL HEALTH OF A PRESCHOOLER

Like the toddler period, the preschool years are not a time of fast growth, so preschool
children are not likely to have ravenous appetites (Raman, 2011). Being certain they get
enough daily exercise helps to improve this. A sense of initiative, or learning how to do
things, can be strengthened by allowing a child to prepare simple foods, such as making
a sandwich or spreading jelly on toast.
Most children are hungry after preschool and enjoy a snack when they arrive home.
Because sugary foods can dull a child’s appetite for dinner and it is not too soon to
begin measures to prevent childhood obesity, urge parents to offer snacks such as fruit,
cheese, or milk rather than cookies and a soft drink or juice (Bevan & Reilly, 2011).
Preschool Nutrition Requirements

As with all age groups, foods selected for preschoolers should include variety (U.S.
Department of Agriculture, 2012) and be based on MyPlate (www.choosemyplate.gov)
recommendations. Preschoolers may not eat a great deal of meat because it can be hard
to chew. Many parents ask whether their preschooler needs to take supplementary
vitamins to make up for this. As long as a child is eating foods from all five food groups
and meets the criteria for a healthy child such as being alert and active with height and
weight within normal averages, additional vitamins are probably unnecessary.
If parents do give vitamins, remind them that a child will undoubtedly view a
vitamin as candy rather than medicine because of the attractive shapes and colors of
preschool vitamins, so they must be stored out of reach. Caution parents not to give
more vitamins than the recommended daily amount, or poisoning from high doses of
fat-soluble vitamins or iron can result.
A Vegetarian Diet
A vegetarian diet is usually colorful and therefore appeals to preschoolers. Vegetables,
fruits, and grains are also healthy snack foods.
If vegetarian diets are deficient in any aspects, it is usually in calcium, vitamin B12,
and vitamin D. Check to be sure a child is ingesting a variety of calcium sources (e.g.,
green leafy vegetables, milk products) because calcium is very important for bone
growth. Vitamin D is found in fortified cereals and milk. Vitamin B12 is found almost
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exclusively in animal products, so a child on a vegetarian intake may need a
supplemental source (Whitney & Rolfes, 2013).
PROMOTING THE DEVELOPMENT OF THE PRESCHOOLER IN

DAILY ACTIVITIES
The preschooler has often mastered the basic skills needed for most self-care activities,
including feeding, dressing, washing (with supervision), and toothbrushing (again, with
supervision).
Dressing
Many 3-year-olds and most 4-year-olds can dress themselves except for difficult
buttons, although conflict may occur over what the child will wear. Preschoolers prefer
bright colors or prints and so may select items that are appealing in color rather than
matching. As with other preschool activities, however, children need the experience of
choosing their own clothes. One way for parents to solve the problem of mismatching is
to fold together matching shirts and slacks so a child sees them as a set rather than
individual pieces. If children insist on wearing mismatched clothing, urge parents to
make no apologies for their appearance. A simple statement, “Mark chose his own
clothes today” explains the situation. Anyone who understands preschoolers appreciates
that the experience children gain in being able to select their own clothing is worth more
than a perfect appearance by adult standards.
Sleep
Many toddlers, who go through a typical negative phase, resist taking naps no matter
how tired they are. Preschoolers, however, are more aware of their needs; when they are
tired, they often curl up on a couch or soft chair and fall asleep. Many, particularly those
who attend afternoon child care or preschool, give up afternoon naps. If they nap at
preschool, they may have some difficulty going to sleep at the usual bedtime established
at home.
On some occasions, even though they may be tired, children in this age group may
refuse to go to sleep because of fear of the dark and may wake at night terrified by a bad
dream (Byars, Yolton, Rausch, et al., 2012). This means that preschoolers may need a
night-light turned on, although they did not need one before. A helpful suggestion for
parents is to screen out frightening stories or TV watching just prior to bedtime and to
be certain when the light in their bedroom is dimmed, it has a soothing atmosphere (no
staring teddy bears or evil smiling dolls). Box 31.5 is an interprofessional care map for a
child with preschool fears.
BOX 31.5
Nursing Care Planning
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AN INTERPROFESSIONAL CARE MAP FOR A PRESCHOOLER WITH
FEARS
Cathy Edwards is a 3-year-old whom you meet at a health maintenance visit. Her
father tells you he is concerned because Cathy talks constantly with an imaginary
friend named Emma. She makes up stories about events that can’t possibly be true.
When corrected, Cathy stutters so badly that no one can understand her. Her father is
also concerned because his daughter cries when he leaves her at child care.
Family Assessment: The family lives in a rented apartment in the inner city. The
mother, a stay-at-home mom, is hospitalized with complications of a second
pregnancy. The father works as a city police detective.
Patient Assessment: A 3-year-old girl within normal limits for height, weight, and
development. The child is currently enrolled in an all-day preschool program while
the mother is hospitalized. The father picks the child up after his work. The father
arrived late to pick the child up from preschool last week. She states, “He forgot me.”
The child refuses to return to preschool. When he tries to drop her off now, she cries,
sticks her finger in her mouth to make herself vomit, and complains her stomach
hurts.
Nursing Diagnosis: Fear related to separation and abandonment during preschool
period.
Outcome Criteria: The child verbalizes fear. The father demonstrates measures to
minimize the child’s fears; reports by 2 weeks that crying episodes at school have
decreased.
Team Member Expected
Responsible Assessment Intervention Rationale Outcome
Activities of Daily Living, Including Safety
Nurse Ask father to Father describes People are Father details a
detail a 24-hour differences in unable to solve typical day and
day for the family life since a problem until expresses his
family to gain wife has been the extent of the wish to continue
clear picture of hospitalized and problem is clear. or not continue
child’s role and strain it causes the preschool
capabilities. on Cathy. experience for
Cathy.
Teamwork and Collaboration
Nurse/nurse Assess if father Encourage the Discussion with Father states he
practitioner feels referral to father to talk care providers will consult
child guidance with the can help with preschool
service is preschool staff reinforce the staff to help
1839
necessary to about the measures used solve the
help reduce fear. problem and by the father to problem.
common provide
methods to consistency and
decrease a thereby help to
child’s fear. minimize a
child’s fears.
Procedures/Medications for Quality Improvement
Nurse Assess what Instruct the Reassurance Father describes
father knows father in helps to reduce steps he will
about measures measures to a child’s fear of take to be
to reduce fear in help reduce abandonment. certain he will
preschoolers. child’s fear, not be late again
such as at preschool for
reinforcing the pickup.
time he will
return, calling if
he’s running
late, and posting
memo to self to
pick her up.
Nutrition
Nurse Assess if child Stress that effect Frequent Father states
uses threat of of eating vomiting in whether he has
vomiting at any disorders is young children ever seen
other time. potentially can lead to fluid pseudovomiting
dangerous. and electrolyte before.
imbalances.
Patient-Centered Care
Nurse/nurse Assess father’s Review with the Knowledge of Father
practitioner knowledge of father the normal growth acknowledges
typical typical fears and he deals mainly
preschool fears experienced by development with adults in
such as the preschooler, helps to reduce his business;
abandonment including those the father’s expresses desire
and fear of the of separation anxiety about to learn more
dark. and the behavior and about preschool
abandonment. possible causes. period.
Psychosocial/Spiritual/Emotional Needs
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Nurse Explore with Encourage the Special time for Father states he
child why she is father to set up a a father and will plan for a
so fearful her special time for daughter special time
father will not himself and his enhances the each week, even
return for her. daughter in the parent–child if it is difficult
evening or on relationship. to arrange
weekends so Consistently because of
they have a adhering to this wife’s
consistent close time helps to hospitalization
time. foster a sense of and his irregular
trust and work schedule.
security and
shows he is
dependable.
Informatics for Seamless Healthcare Planning
Nurse Assess if father Arrange for a Follow-up Father states he
would find a follow-up provides is receptive to
follow-up telephone call additional follow-up care.
telephone call (if desired) in 1 support and
helpful. week. means for
evaluating the
effectiveness of
the methods
used.

EVIDENCE-BASED PRACTICE
Many preschoolers have difficulty falling asleep or wake during the night with
nightmares. To see if changes in the type of television watched could improve
preschooler’s sleep, researchers encouraged half of a group of families studied to
replace television watching with quality educational and prosocial video content
through use of an initial home visit and follow-up telephone calls over 6 months.
Among the 565 children studied, the most common sleep problem was delayed sleep
onset (38%). Results at the end of 18 months showed that children in the intervention
group had significantly lower odds of any sleep problems (Garrison & Christakis,
2012).
Based on the study, what is the best advice the nurse could give the Edwards
family?
a. Don’t allow Cathy to watch television until she is 5 years of age.
b. Encourage Cathy to watch specific DVDs that her parents choose for her.
1841
c. Discuss with Cathy that TV does not necessarily reflect reality.
d. Allow her to only watch cartoons so she won’t be seeing violence.
Exercise
The preschool period is an active phase, so preschool play tends to be vigorous.
Roughhousing helps relieve tension and should be allowed as long as it does not
become destructive. In addition, preschoolers love time-honored games such as ring-
around-the-rosy, London Bridge, or other more structured games they were not ready
for as toddlers. Promoting these types of active games and reducing television watching
can be steps toward helping children develop motor skills as well as prevent childhood
obesity (Hodges, Smith, Tidwell, et al., 2012; Mitka, 2012).
Hygiene
Preschoolers can wash and dry their hands adequately if the faucet is regulated for them
(so they do not scald themselves with hot water). When possible, parents should turn
down the temperature of the water heater in their home to under 120°F to help prevent
scalds.
Although preschoolers certainly sit well in bathtubs, they should still not be left
unsupervised at bath time in case they decide to add more hot water or to practice
swimming and then be unable to get their head out of the water again. Some girls
develop vulvar irritation (and perhaps bladder infections) from exposure to bubble bath
so parents shouldn’t add such products to the water (S. Smith, 2011). Although not well
studied, cranberry juice may help prevent these infections the same as in adult women
(Goldman, 2012).
Children this age are not paragons of neatness and may not clean their hands
thoroughly. Preschoolers do not clean their fingernails or ears well, either, so these areas
often need “touching up” by a parent or older sibling. Using a nonirritating shampoo
and hanging a mobile over the tub so they have a reason to look up while their hair is
rinsed helps make hair washing a fun procedure.
Care of Teeth
If independent toothbrushing was not started as a daily practice during the toddler years,
it should be started during preschool (G. A. Smith & Riedford, 2012). One good
toothbrushing period a day is often more effective than more frequent half-hearted
attempts. Electric or battery-operated toothbrushes are favorites of preschoolers and can
be used safely if the child is taught not to use it or any other electrical appliance near a
basin of water. Although many preschoolers do well brushing their own teeth, parents
must check that all tooth surfaces have been cleaned. Parents should also floss the
child’s teeth because this is a skill beyond a preschooler’s motor ability.
Preschoolers should continue to drink fluoridated water or receive a prescribed oral
1842
fluoride supplement if fluoride is not provided in the water supply (Tubert-Jeannin,
Auclair, Amsallem, et al., 2011). Encouraging children to eat apples, carrots, chicken, or
cheese for snacks rather than candy or sweets is yet another way to prevent tooth decay.
If a child is allowed to chew gum, it should be the sugar-free variety.
A first visit to a dentist should be arranged no later than 2 years of age for an
evaluation of tooth formation because deciduous (baby) teeth must be preserved to
protect the dental arch. Dental services can be performed at 3 years of age. If a tooth has
to be pulled for any reason, this can cause the permanent teeth to drift out of position or
the jaw not to grow enough to accommodate them (Merlino & Gigli, 2012). Because
initial visits usually reveal no cavities, this should be a pain-free experience and should
help implant the idea that dentists like to help rather than hurt.
Teeth grinding (bruxism) may begin at this age as a way of “letting go,” similar to
body rocking, which children do for a short time each night before falling asleep.
Children who grind their teeth extensively may have greater than average anxiety.
Children who have cerebral palsy may do this because of the spasticity of jaw muscles.
If grinding is extensive, the crowns of the teeth can actually become abraded. The
condition can advance to such an extent that tooth nerves become exposed and painful.
If damage is evident, refer the family to a pediatric dentist so the teeth can be evaluated,
repaired (capped), and conserved.
What If . . . 31.3
Cathy’s father tells the nurse she hates to take a bath and brush her teeth.
What suggestions could the nurse make to help Cathy enjoy these bedtime
activities more?
PROMOTING HEALTHY FAMILY FUNCTIONING

An important role of preschooler parents is to respect creativity. Some who enjoyed
maintaining a gentle rhythm of care for an infant can have difficulty being the parents of
a preschooler because more flexibility and creativity are required. Other parents come
into their own as their child reaches 3 years; they delight in encouraging imaginative
games and play.
Part of encouraging creativity is encouraging vocabulary building. One way for
parents to do this is to read aloud to their child; another is to answer questions so the
child sees language as an organized system of communication. Answering a
preschooler’s questions can be difficult, because the questions are frequently
philosophical, not fact finding such as, “Why is grass green?” A child may listen to an
explanation of chlorophyll but then repeat the question, regardless of the clarity of the
explanation, because the parent underestimated the depth of the question. The child did
not want to know what makes grass green but why, philosophically, it is not red, blue,
or yellow. The obvious answer to that is “I don’t know.” Parents who are confident can
1843
give this answer without feeling threatened. Parents who are less sure of themselves
may feel extremely uncomfortable when they realize they do not know the answer to
what a 4-year-old is asking (Box 31.6).
BOX 31.6
Nursing Care Planning Tips for Effective Communication
Cathy is being seen for a health maintenance visit. You overhear her father talking to
his daughter in the waiting room.
Tip: Preschoolers ask 300 to 400 questions a day as they explore their world.
Encourage parents to more completely answer their child’s questions by explaining
they are helping to build their child’s vocabulary. Parents sometimes try to
discourage questions by offering minimal answers, and discouraging questions can
become the habitual method of interaction.
Cathy: Why do we have to wait so long?
Mr. Edwards: It’s how things work here.
Cathy: Why?
Mr. Edwards: People have to take turns. We’re waiting for our turn.
Cathy: Why is that girl here? Is she sick?
Mr. Edwards: She might be. Some children are here because they’re sick and some
are just here for a checkup like you.
Cathy: When are we going home?
Mr. Edwards: As soon as the nurse practitioner checks you over.
Cathy: What’s that girl’s name?
Mr. Edwards: I don’t know. Do you want to ask her?
Discipline
Preschoolers have definite opinions on things such as what they want to eat, where they
want to go, and what they want to wear, and these opinions may bring them into
opposition with parents. A major parental responsibility when this happens is to guide a
child through these struggles without discouraging the child’s right to have an opinion.
A “time-out” is a useful technique for parents to correct behavior throughout the
preschool years (see Chapter 30). Although the technique has some critics, it allows
parents to discipline without using physical punishment and allows a child to learn a
new way of behavior without extreme stress. Time-out periods should be as many
minutes long as the child is old, so 3 to 5 minutes is appropriate for preschoolers.
1844
PARENTAL CONCERNS ASSOCIATED WITH THE PRESCHOOL
PERIOD
A number of common health problems and fears usually arise during the preschool
years.
Common Health Problems of the Preschooler

The mortality of children during the preschool years is low and becoming lower every
year as more infectious diseases are preventable. This results in the major cause of death
being automobile accidents, followed by poisoning and falls (Centers for Disease
Control and Prevention [CDC], 2012).
Even though the number of major illnesses is few in this age group, the number of
minor illnesses, such as common colds and ear infections, are high. Children who live in
homes in which parents smoke have a higher incidence of ear (otitis media) and
respiratory infections than others (Yilmaz, Caylan, & Karacan, 2012). Children who
attend child care or preschool programs also have an increased incidence of
gastrointestinal disturbances (vomiting and diarrhea) and upper respiratory infections
from the exposure to other children unless frequent hand washing is stressed at the
setting (Sun & Sundell, 2011).
Children may demonstrate frequent whining or clinging behavior because of this
parade of constant minor infections. Assess to be certain such constant illness is not
causing parents to perceive a child as sickly or not able to cope with everyday life so
they don’t begin to discourage independence in favor of overprotection. As parents
become more experienced in handling these conditions, their perception of whether an
illness is serious or not and their ability to cope with them will change.
Table 31.2 shows the recommended health maintenance schedule for preschoolers.
Table 31.3 lists common problems parents may have in evaluating a preschooler’s
illness.
TABLE 31.2 HEALTH MAINTENANCE SCHEDULE, PRESCHOOL PERIOD

Area of Focus Methods Frequency
Assessment
Health history Health interview Every visit
Physical health Physical examination Every visit
Developmental History, observation Every visit
milestones
Formal Denver Developmental Before start of
Screening Test (DDST-II) school
Growth milestones Height and weight plotted on standard Every visit
growth chart; body mass index
1845
(BMI) and physical examination
Hypertension Blood pressure Every visit
Nutrition History, observation; height and weight Every visit
information
Parent–child History and observation Every visit
relationship
Social behavior History and observation Every visit
Vision and hearing History and observation Every visit
defects
Preschool E stereo and audiometer Before start of
testing school
Autism spectrum History and observation At 18 and 24 months
disorder screening
Dental health History, physical examination Every visit
Dental visit Every 6 months
Fluoride varnish Recommended each
visit
Dyslipidemia Cholesterol, triglycerides If indicated by risk
Lead Blood analysis (depending on risk in If indicated by risk
area)
Tuberculosis Purified protein derivative (PPD) test If indicated by risk
(if there are high-risk factors)
Immunizations
(Administer immunization in accordance with healthcare agency policies. Check
history and past records and inform caregiver about any risks and side effects before
administration [www.cdc.gov/vaccines/schedules].)
Diphtheria, pertussis, DTaP 5 Before start of
and tetanus school
Measles, mumps, and MMR #2 Before start of
rubella (MMR) school
Poliomyelitis IPV #4 Before start of
(inactivated) school
Varicella VAR #2 Before start of
school
Influenza IIV Yearly
Pneumococcal Pneumococcal conjugate vaccine May be indicated
1846
(PCV) before school in
susceptible
children
Anticipatory Guidance
Preschool care Active listening and health teaching Every visit
Expected growth and Active listening and health teaching Every visit
developmental
milestones before
next visit
Unintentional injury Counseling about street and personal Every visit
prevention safety
Problem Solving
Any problems expressed Active listening and health teaching Every visit
by caregiver during regarding preschool illnesses and
course of the visit imaginative play
Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. (2012).
Recommendations for preventive pediatric health care. Washington, DC: Author; Centers for Disease Control
and Prevention. (2013). Birth–18 years and “catch up” immunization schedules. Washington, DC: Author.
TABLE 31.3 PARENTAL DIFFICULTIES EVALUATING HEALTH

PROBLEMS IN THE PRESCHOOL CHILD
Difficulty Helpful Suggestions for Parents
Evaluating seriousness of Preschoolers are eager to please and tend to answer all
illness or condition questions such as “Does your stomach hurt?” with a yes.
Observing the child for signs of illness (e.g., refusing to
eat, holding an arm stiffly, having to go to the bathroom
frequently) is often more productive as an evaluation
technique.
Evaluating bowel and Preschoolers are independent in toilet habits for the first
bladder problems time, so parents do not have diaper contents to evaluate.
Frequent trips to the bathroom, rubbing the abdomen, and
holding genitals are the usual signs of bowel or bladder
dysfunction.
Evaluating nutritional Preschoolers begin to eat away from home at friends’ houses
intake or at child care, or stay overnight with grandparents for
the first time, so parents have less opportunities to observe
daily food intake as accurately as before. Observing
whether a child is growing and is active is better than
monitoring any one day’s intake.
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Evaluating bed-wetting Many preschoolers continue to have occasional enuresis at
night until school age. If other signs are present (e.g.,
pain, low-grade fever, listlessness), a child should have a
urine culture because persistent bed-wetting can indicate a
low-grade urinary tract infection.
Evaluating activity Many lay magazines have articles on hyperactivity in
versus hyperactivity children. Parents wonder whether their active child could
be hyperactive. As a rule of thumb, if a child can sit
through a meal (when he is hungry), watch a half-hour
television show (that is his favorite), or sit still while his
favorite story is read to him, he is not hyperactive.
Age-specific diseases to Preschool age is a time for vision and hearing assessment
be aware of because, for the first time, a child is able to be tested by a
standard chart or by audiometry tests.
Urinary tract infections tend to occur with a high frequency
in preschool-age girls.
A language assessment should be done if a child is not able
to make wants known by complete, articulated sentences
by age 3 years (exceptions are transposing w for r and
broken fluency: “I want-want-want to go”).
Common Fears of the Preschooler

Because preschoolers’ imaginations are so active, this leads to a number of fears such as
fear of the dark, mutilation, and separation or abandonment. These can rise in incidence
when combined with the stress of an illness, hospitalization, or unsafe conditions in the
child’s community (Kushnir & Sadeh, 2011). Although most of these fears can be
handled by comforting from parents, in some children, fears are so intense that they
need therapy such as desensitization in order for the fear to be conquered.
Fear of the Dark

The tendency to fear the dark is an example of a fear heightened by a child’s vivid
imagination: a stuffed toy by daylight becomes a threatening monster at night. Children
awaken screaming because of nightmares. They may be reluctant to go to bed or go
back to sleep by themselves unless a light is left turned on or a parent sits nearby.
If parents are prepared for this fear and understand it is a phase of growth, they are
better able to cope with it. It is generally helpful if they monitor the stimuli their
children are exposed to, especially around bedtime. This includes television, adult
discussions, and frightening stories. Parents are sometimes reluctant to leave a child’s
light on at night because they do not want to cater to the fear. Leaving on a dim night-
light, however, can solve the problem and costs only pennies. Children who awake
1848
terrified and screaming need reassurance that they are safe and that whatever was
chasing them was a dream and is not in their room (Fig. 31.4). Most preschoolers do not
remember in the morning that they had such a dream; however, they remember for a
lifetime that they received comfort when they needed it.
Figure 31.4 Having mom close by after a bad dream is a comfort to a

preschooler.
If parents take sensible precautions against fear of the dark or nightmares and a child
continues to have this kind of disturbance every night, it may be a reaction to undue
stress, which needs to be investigated and eliminated. Giving sleep medication to
counteract the sleep disturbance does not solve the basic problem, so this is rarely
recommended. Fear of the dark and sleep disturbances both can become intensified in a
hospital setting and require careful planning to relieve (Linder & Christian, 2011).
Fear of Mutilation
Fear of mutilation is also significant during the preschool age, as revealed by the intense
reaction of a preschooler to even a simple injury such as falling and scraping a knee or
having a needle inserted for an immunization. A child cries afterward not only from the
pain but also from the intrusiveness of the injury or procedure. Part of this fear arises
because preschoolers do not know which body parts are essential and which ones—like
an inch of scraped skin—can be easily replaced. According to Freud, boys develop a
fear of castration because, developmentally, they are more in tune with their body parts
and are starting to identify with the same-sex parent as they go through the Oedipal
phase (Zepf, Ullrich, & Seel, 2016).
Preschoolers can be worried that if some blood is taken out of their bodies, all of
1849
their blood will leak out. They often lift a bandage to peek at an incision or cut to see if
their body is still intact underneath. They dislike procedures such as needlesticks, rectal
temperature assessments, otoscopic examinations, or having a nasogastric tube passed
into their stomach. They need good explanations of the limits of healthcare procedures,
such as clarifying a tympanic thermometer does not hurt or a finger prick heals quickly
as well as distraction techniques in order to feel safe.

PATIENT-CENTERED CARE
Cathy keeps her entire family awake at night because she is so afraid of the dark. The
nurse teaches Cathy’s parent to take which action to help overcome this fear?
a. Assure Cathy the room’s window is locked so no one can kidnap her.
b. Suggest Cathy temporarily sleep in the living room in front of the television
set for safety.
c. Buy a night-light for Cathy’s room and inspect the room to be certain it
appears safe.
d. Teach Cathy that her fear is not grounded in reality.
Fear of Separation or Abandonment

Fear of separation is yet another major concern for preschoolers. Their sense of time is
still so distorted that they cannot be comforted by assurances such as “Mommy will
pick you up from preschool at noon.” Their sense of distance is also limited, so making
a statement such as “I work only a block away” is not reassuring. Relating time and
space to something a child knows better, such as meals, television shows, or a friend’s
house, is more effective. For example, stating, “Mommy will pick you up from
preschool after you have had your snack” is apt to be more comforting than “Mommy
will pick you up at 3 PM.”
Caution parents to be sensitive to such fears when they talk about missing children
or if they have their preschooler’s photo or fingerprints taken for identification.
Children whose chief fear is that they will be abandoned or kidnapped might be alarmed
someone will take them away from their parents and not understand their fingerprints
are being taken to keep them safe.
A hospital admission or going to a new school often brings a child’s fear of
separation to the forefront. Help parents thoroughly prepare preschoolers for these
experiences so they can survive them in sound mental health (see Chapter 35). Help
them give clear instructions on when they will visit the child in the hospital.
Behavior Variations
A combination of a keen imagination and immature reasoning results in a number of
1850
other common behavior variations in preschoolers.
Telling Tall Tales

Stretching stories to make them seem more interesting is a phenomenon frequently
encountered in preschoolers. For example, after a trip to the zoo, if you ask a
preschooler, “What happened today?” a child perceives you want something exciting to
have happened, and so might answer, “A bear jumped out of his cage and ate the boy
next to me.” This is not lying, but merely supplying an expected answer. Parents may be
concerned that tall tales of this nature can lead to chronic lying if supported. Caution
them not to encourage this kind of storytelling but instead help the child separate fact
from fiction by saying, “That’s a good story, but now, tell me what really happened.”
This conveys the idea that the child has not told the truth, yet does not squash
imagination or initiative (Talwar & Crossman, 2011). On the other hand, parents must
be alert to not dismiss important information inadvertently such as children reporting an
adult molesting them.

SAFETY
Cathy’s father, a police detective, says that he and his wife wish to take measures to
prevent Cathy from being kidnapped. What action should the nurse recommend to
this family?
a. Limit playdates to Cathy’s own home.
b. Withdraw Cathy from daycare to limit her exposure to other adults.
c. Describe common kidnapping culprits the father knows.
d. Be certain Cathy understands not to leave daycare with anyone but her
parents.
Imaginary Friends
Many preschoolers have an imaginary friend who plays with them (Nielsen, 2012).
They tell a parent to “wait for Eric” or to “set a place at the table for Lucy.” Although
imaginary friends are a normal, creative part of the preschool years and can be invented
by children who are surrounded by real playmates as well as by those who have few
friends, parents may find them disconcerting. If so, let parents know that as long as their
child has exposure to real playmates and imaginary playmates do not take center stage
in children’s lives or prevent them from socializing with other children, they should not
pose a problem and often leave as quickly as they come. In the meantime, pretend
friends can encourage language development, may provide an outlet for a child to
express innermost feelings, or serve as a handy scapegoat for behavior about which a
child has some conflict.
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Parents can help their preschooler separate fact from fantasy about their imaginary
friend by saying, “I know Eric isn’t real, but if you want to pretend, I’ll set a place for
him.” This response helps a child understand what is real and what fantasy is without
restricting imagination or creativity.
Difficulty Sharing
Sharing is a concept that first comes to be understood around the age of 3 years. Before
this, children engage in parallel play (two children need two toys and two spaces to play
because they cannot pass one toy back and forth or play together). Around 3 years of
age, children begin to understand some things are theirs, some belong to others, and
some can belong to both. For the first time, they can stand in line to wait for a drink,
take turns using a shovel at a sandbox, and share a box of crayons. Sharing does not
come easily, however; children who are ill or under stress have greater difficulty with it
than usual.
Assure parents that sharing is a difficult concept to grasp, and, as with most skills,
preschoolers need practice to understand and learn it (Sutherland & Friedman, 2012).
Parents may need to help a child learn property rights as part of learning to share, such
as “This is my private drawer and no one touches what is in it but me.” “That is your
private box, and no one touches the things in it but you.” “A shovel is ours and can be
used by everyone playing in the sand pile.” Defining limits and exposing children to
these three categories (i.e., mine, yours, ours) helps them determine which objects
belong to which category.
Regression
Some preschoolers, generally in relation to stress, revert to behavior they previously
outgrew, such as thumb-sucking, negativism, loss of bladder control, and inability to
separate from their parents. Although the stress that causes this may take many forms, it
is usually the result of such things as a new baby in the family, a new school experience,
seeing frightening and graphic television news or programming, stress in the home from
financial or marital difficulties, or separation caused by hospitalization.
Help parents understand that regression in these circumstances is normal, and a
child’s thumb-sucking is a little different from the parents’ reaction to stress (e.g.,
smoking many cigarettes, nail biting, overeating), so it’s easier for them to accept and
understand. Obviously, removing the stress is the best way to help a child discontinue
this behavior. The stresses mentioned, however, are not ones that are easily controlled.
New babies cannot be returned, irreparable marriages cannot be patched together,
frightening news happens every day, and hospitalizations do occur.
Techniques for minimizing the stress of hospitalization for preschoolers are
discussed in Chapter 35. Children’s reactions to severe and prolonged stress are
discussed in Chapter 54. Children undergoing less severe stress can be assured that
although situations are changing, the important aspect of their life—that someone still
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loves them and will continue to take care of them—is not. The manifestations of stress,
such as thumb-sucking, are best ignored; calling them to a child’s attention merely
causes more stress because, in addition to experiencing the primary stress, it makes
children aware they are not pleasing their parents.
Sibling Rivalry
Jealousy of a brother or sister may first become evident during the preschool period
because this is the first time children have enough vocabulary to express how they feel
(i.e., know a name to call) and partly because preschoolers are more aware of family
roles and how responsibilities at home are divided (Snowling, 2011). For many
children, this is also the time when a new brother or sister is born.
A firstborn child is rarely allowed the privileges of a second child. The parents are
untried, unsure of how far they should let a first child venture or what level of
responsibility a child could accept, allowing the firstborn to serve as the “trial run” for
all children who come after. Children as young as preschool can tell when a younger
sibling is allowed behavior that is not tolerated in them. They are little appeased by the
explanation, “Your brother is just a baby.”
To help preschoolers feel secure and to promote self-esteem during this time,
reminding them that there are things they can do that a younger sibling is not allowed to
do and supplying them with a private drawer or box for their things that parents or other
children do not touch can be helpful. A private box serves as a defense against younger
children who do not yet appreciate property rights.
Preparing for a New Sibling

Introduction of a new sibling is such a major happening that parents need to take special
steps to be certain their preschooler will be prepared (Volling, 2012). There is no rule as
to when this preparation should begin, but it should be before the time the child begins
to feel the difference the new baby will make. This is perhaps when the mother first
begins to look pregnant. It is certainly before parents begin to make physical
preparations for the new child. It is always less frightening to understand why things are
happening, no matter how distasteful they may be rather than hear people whispering or
having people obviously evading the issue. The unknown is always more fearful than a
definite event because those can be faced and conquered.
Help parents not to underestimate the significance of a bed to a preschool child
because it is security, consistency, and “home.” If their preschooler is sleeping in the
crib that will be used for the new baby, it’s usually best if the preschooler can be moved
to a bed about 3 months in advance of the birth. Parents might explain, “It’s time to
sleep in a new bed now because you’re a big girl.” The fact that the child is growing is a
better reason for such a move than because a new brother or sister needs their bed. The
latter may be a direct route to sibling rivalry and jealousy.
If children are to start preschool or child care, it’s also best if they can do so either
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before the new baby is born or 2 or 3 months afterward. That way, children can perceive
starting school as a result of maturity and not of being pushed out of the house by the
new child.
If the mother will be hospitalized for the birth, parents should be certain their child
is prepared for this separation. Because the mother is likely to go to the hospital during
the night, it is unrealistic to expect a child to be happy to learn in the morning about the
arrival of a new sibling when he realizes the new baby has taken away his mother. Some
communities offer preparation for birth classes for preschoolers, the same as for parents,
or to include children in adult preparation courses to help them master this new
experience.
Encourage women to maintain contact with their preschooler during the short time
they are hospitalized for the new birth. Some preschoolers may react very coldly to their
mothers, turning their head away and refusing to come to them after even a few days of
separation when they return home. This is a reaction not to the new baby but to the
separation, and the same phenomenon that may occur when a child returns home after
being hospitalized (see Chapter 35). Allowing the child to visit in the hospital can help
relieve this type of separation anxiety.
Ask pregnant women or couples what kind of preparation they are making for older
children and ask the mother of a new baby how everything is working out. Most parents
find the problem of jealousy is bigger than they anticipated and welcome a few
suggestions about how to provide more time for their preschooler during the day or
which activities a preschooler would especially enjoy (Fig. 31.5 and Box 31.7).
Figure 31.5 A preschooler greets a new baby sister. She feels special
as dad explains how important it is to be a big sister.
BOX 31.7
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Nursing Care Planning Based on Family Teaching
ANTICIPATORY GUIDANCE TO HELP MINIMIZE SIBLING
RIVALRY
Q. Cathy’s father says to you, “Cathy’s acting jealous of her new sister and she’s not
even born yet. What can we do to reduce sibling jealousy?”
A. This isn’t a simple problem, but the following suggestions might be helpful:
• After returning home from the hospital with the baby, devote attention to your
preschooler and spend some special time together after the baby has gone to bed.
• When friends and family visit, encourage them to spend time with the preschooler
as well as the baby. If they bring gifts for the baby, it is often wise for them to
bring a small present for the preschooler as well.
• So your preschooler doesn’t come to expect gifts (promoting sibling rivalry), teach
her to help open the baby’s gifts. Explain it is the baby’s birthday and on her
birthday she will receive gifts, too.
• Don’t ask your preschooler a question such as “Do you like your new sister?” It is
better to express feelings of empathy such as “New babies cry a lot. It’s hard to get
used to that, isn’t it?”
• Provide special time for your preschooler during each day, so when you say,
“Mommy and Daddy love you just the same,” it seems real. This might be a quiet
time for talking or reading.
• While feeding the baby, read or tell a story to your preschooler. Some children
enjoy feeding a doll while a parent feeds the baby or giving a doll a bath while the
baby has one.
Concept Mastery Alert
A new baby makes a significant difference in a child’s life. To reduce the child’s
feeling of being “replaced” by the new baby, significant changes, such as starting
preschool, should be done either well before the new baby is born or 3 to 4 months
afterward.

TEAMWORK & COLLABORATION
Cathy’s family is expecting a new baby. When Cathy is visiting the birthing center,
the nurse should promote which behavior as a means of fostering family bonding
during this time of transition?
a. Take action to help Cathy spend as much time with her mother and the infant
as possible.
b. Teach Cathy about the ways that her life might change after the birth of the
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baby.
c. Remind Cathy that her parents love her very much.
d. Explain to Cathy that she’s very lucky because sisters grow up to become best
friends.
Sex Education
During the preschool age, children become acutely aware of the difference between
boys and girls. Possibly, this is a normal progression in development, and, possibly, this
may be the first time they are exposed to the genitalia of the opposite sex as they watch
while a new brother or sister has a diaper changed, they see other children using the
bathroom at a preschool, or they see a parent nude.
Preschoolers’ questions about genital organs are simple and fact finding; for
example, “Why does James look like that?” or “How does Jasmine pee?” Explanations
should be just as simple: “Boys look different from girls. The different part is called a
penis.” It is important that parents do not convey that these body parts are never to be
talked about so they leave an open line of communication for sexual questions.
Occasionally, girls attempt to void standing up as they have seen boys doing, and boys
may try to void sitting down as they try to use this new body knowledge.
It is common for preschoolers to engage in masturbation while watching TV or
before they fall asleep at night. The frequency of this may increase under stress, as does
thumb-sucking. If observing a child doing this bothers parents, suggest they explain
certain things are done in some places but not in others. Children can relate to this kind
of direction without feeling inhibited, just as they can accept the fact they use a
bathroom in private or eat only at the table. Calling unnecessary attention to the act can
increase anxiety and cause increased, not decreased, activity.
Because this may be the time a new brother or sister comes into the family, it is also
the most likely time for questions such as “Where do babies come from?” Because a
child is asking a simple fact-finding question, parents usually find a simple, factual
answer to this type of question is best, such as “Babies grow in a special place in a
mother’s body called a uterus.” Saying “uterus” rather than “tummy” prevents children
from envisioning babies and food all mixed together in their mother’s stomach (Fig.
31.6).
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Figure 31.6 Preschool children have the beginnings of sexual
awareness and are interested in learning where babies grow. (Taeke
Henstra/Science Source/Photo Researchers, Inc.)
It is so natural for preschoolers to ask about where babies come from that those who
do not ask are exceptions and may not be asking because they sense from a preliminary
exploratory question that the subject is closed. A parent could introduce the subject by
visiting a new baby in the neighborhood with the child or pointing out a neighbor who
is pregnant. Visiting new kittens or puppies can also offer the chance to introduce the
subject. If a new brother or sister will be born at a birthing center or at home, many
parents may want their preschooler to be present at the birth. Encourage parents to
prepare children thoroughly for this experience, or else the sight of their mother in pain
and the wonder of birth can become an overwhelming and negative experience rather
than a positive one for them (see Chapter 14).
Preschool children generally do not ask how babies get inside mothers to start
growing or how babies get out at the end of the process.
Many books for children explain the birth process, same-sex parenting, and
adoption. These are helpful for parents to read to a child to increase understanding if
they feel the child is ready for longer explanations. Correct terminology should be used
when providing an explanation to a child.
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QUALITY IMPROVEMENT
The nurse is drafting an educational handout for parents of preschoolers that
addresses the topic of sex education. What guideline should be included in this
educational material?
a. Tell your child that you will explain these matters when they are old enough
to start kindergarten.
b. Emphasize the fact that sexual intercourse between adults must always be
consensual.
c. Describe some of the differences between boys and girls in clear and accurate
terms.
d. Distract your child from questions about sexuality for as long as possible.
Another important part of sex education for preschoolers is teaching them to avoid
sexual maltreatment, such as not allowing anyone to touch their body unless they and
their parents agree that it is all right (Pérez-Fuentes, Olfson, Villegas, et al., 2012).
Because children have been taught this, remember to ask permission before giving
nursing care that involves touching, especially before procedures such as catheterization
or clean catch urines (see Chapter 32, Box 32.4).
Choosing a Preschool or Child Care Center

A school or child care experience is helpful for preschoolers because peer exposure
seems to have a positive effect on social development (Gubbels, Van Kann, & Jansen,
2013). Children who have learned to be comfortable in a preschool group, for example,
approach school comfortably and ready to learn; children who have played only
infrequently in groups during the preschool age can be so busy adjusting to this new
concept that they are left behind in learning new skills in kindergarten or first grade.
Most parents enroll their child in a child care program because both parents work
outside their home. A parent who is at home full-time has to weigh whether it would be
best for a child to have socialization experiences or to not diminish the family time.
The terms “child care center” and “preschool” are often used interchangeably, so
parents cannot depend on the name of a school to define its structure. Traditionally, the
main purpose of a child care center is to provide child care while parents work or are
otherwise occupied. A preschool is dedicated to stimulating children’s sense of
creativity and initiative and introducing them to new experiences and social contacts
that they would not ordinarily receive at home. Head Start programs and many modern
child care centers fulfill both functions (Wrobel, 2012).
If there are other 3- or 4-year-old children in a neighborhood with whom a child has
almost daily contact and if a parent can supervise organized play dates and projects
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(providing peer interaction, in which working together is the key), a preschool program
may not be necessary. However, if all the neighborhood children are either older or
younger or there is only one other child available to play with during the day, a
preschool experience will probably be beneficial. Parents with large families point out
that their child gets ample exposure to groups because every meal is a “group session.”
This is not a peer group, however, so this situation does not offer the same experience as
does preschool.
Be sure parents investigate preschools or child care centers carefully before they
enroll their child to be certain their child will not only be safe there but also that the
child will have an enjoyable experience. Guidelines to aid parents in this assessment are
shown in Table 31.4.
TABLE 31.4 QUESTIONS TO USE IN EVALUATING CHILD CARE CENTERS

Question Finding
Management
How long has the Length of operation does not necessarily indicate quality, but it
center been in allows you to locate other parents who have used the center to
operation? ask about their experience there.
Is the center Ask in your local community what agency has the responsibility
licensed, for licensing child care centers. If not licensed, its quality is
registered, suspect.
approved, or
inspected by the
appropriate
agency?
What are the If staff members are teachers, more learning activities will be
qualifications of provided; staff should be qualified to perform
staff members? cardiopulmonary resuscitation.
Is there a fast A fast turnover rate means little continuity of care will be
turnover rate of provided (and probably suggests dissatisfaction with center
staff? administration).
What is the child– A ratio of three or four children to one staff member provides
staff ratio? time for quality interaction.
What is the center’s Parents should be able to drop in at any time. Be wary of
policy on parental facilities that restrict parental visiting in any way.
visits?
Physical Environment
Is there adequate There should be opportunities for rough-and-tumble and
space in the imaginative play in addition to naptime areas and table
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center? activities.
Does the space Stairways should be fenced. No paint should be peeling.
appear safe?
Can children get in A first-floor plan is safest. Fire exits should be well marked. An
and out of the evacuation plan should be practiced.
building easily?
Is there a safe play Find out how often children are taken outside: once or twice a
area for children day, or only occasionally for “outings”?
outside?
Is there a quiet place Ask if a child can nap if tired or has to wait until a set naptime.
for naps?
Can the bathroom be Both potty chairs and small toilet seats should be available.
reached easily?
If food is provided, Food should be preschool friendly and healthy, not just high-fat
does it meet snacks.
preschool
recommendations?
Is there adequate Food poisoning is a concern without refrigeration.
refrigeration?
Staff Philosophy
Are the caregivers Watch how they greet children. They should ask questions and
warm and listen to answers.
affectionate
toward children?
Do caregivers spend It is best if the cleaning staff are separate from the care staff.
most of their time
performing
janitorial tasks
(cleaning) or
devoting their
time to children?
Is each child Ask caregivers to describe their care pattern; if this is not
assigned to a planned, little continuity of care results.
particular
caregiver on a
continuing basis?
Are the children Imaginative items, such as a puppet theater, finger paint, and
provided water play, should be included.
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stimulating toys
and equipment?
How do caregivers The method should reflect the parents’ philosophy. Staff should
discipline be able to talk to children calmly without raising their voices
children? Do they in anger.
yell or treat the
children roughly?
Is there a planned There should be specific goals the caregivers hope to
curriculum? accomplish.
Can the child pursue Play or learning activities should be individualized.
an individual
interest?
Healthcare Protocols
How does the center There should be access to a nurse. Staff should be able to
care for an ill evaluate for illness.
child?
They should know actions to take in an emergency.
What precautions do The counter where diapers are changed should be wiped with a
caregivers take to disinfectant; tissues and hand-washing facilities should be
prevent the spread present.
of infection?
Does the center Be sure the center requires waterproof disposable diapers to
follow good minimize contamination of the environment and other children
sanitary practices? and separates diaper-changing areas from other activities,
especially anything related to food handling. Observe
caregivers changing diapers. Do they wash hands after each
change? Are children encouraged to wash their hands before
eating?
Under what A center should have a very specific policy on what illness
conditions are symptoms require a child to be kept home, and they should
children not enforce this policy strictly. For instance, a runny nose may be
allowed to attend acceptable, but a fever is not, and children with chickenpox
the center? should be kept at home until the lesions are covered with
scabs. Children with special needs should be integrated into
usual activities.
Children’s Behavior
Do the children Observe for at least one morning.
appear happy and
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relaxed?
Do children rush to This could be a sign of boredom with their center’s activities and
greet any new a strong need for adult attention.
visitors?
To continue to evaluate their child’s school experience, urge parents to make a habit
of asking children what happened at school, what they learned, and the names of any
new friends. For the remainder of the growing years, school will have important
influences on their child’s development. By taking an active role in education, parents
influence what and how their child learns.
Child care centers may be responsible for the spread of infectious disease among
those age 5 years and under because bringing together children from so many different
homes to one setting each day increases the risk of spreading contagious disease.
Preschoolers in child care settings may develop frequent upper respiratory infections or
gastrointestinal illnesses. Outbreaks of cytomegalovirus and human parvovirus (fifth
disease) make working in such centers a particular hazard to pregnant women because
such illnesses are potentially teratogenic. To prevent the spread of infection, children
need to wash their hands frequently and cover their mouths with their sleeve when
coughing. Child care centers where infants are enrolled need to take special precautions
against hepatitis A or parasitic infections because these can be spread by caregivers not
washing their hands or not washing tables after changing diapers. Hepatitis may be
subclinical in the preschooler, but other members of the preschooler’s family can
develop overt symptoms as the illness spreads through the family, making vaccinations
important (CDC, 2011).
Preparing a Child for School

At the end of the preschool period, children begin a formal school experience as they
enter kindergarten. Parents may wonder whether their child is old enough for this,
especially if a child’s birthday is in the late summer or early fall. If this is a concern,
urge parents to discuss their concern with school officials to determine whether their
child should be registered for kindergarten or delayed for a year. Because school
involves a great deal of children’s time and influences their future greatly, it’s important
for parents to take time to prepare preschoolers not only physically, by being certain
their immunizations are up-to-date (see Table 31.2), but also emotionally.
Essential to this preparation is the parents’ attitude. If school is discussed as
something to look forward to, as an adventure that will be satisfying and rewarding, a
child comes to look forward to it as a positive experience. If school is presented as a
punishment (“Wait until you get into first grade—your teacher will make you behave”),
there can be little delight in anticipating it.
If a child was not attending preschool, some parents may have to change their
child’s daily routine a few months in advance of beginning school to accustom the child
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to waking earlier or going to bed earlier. School has so many new components that it’s
wise for parents to try to eliminate as many distractions as possible.
If a child is to ride a bus to school, a parent might take a child on a municipal bus as
an introduction to this form of transportation. If a child is to walk to school, a trial walk
is in order. In either instance, safety should be stressed such as “Don’t walk behind the
bus because the driver can’t see you” and “Wait for the crossing guard to help you cross
the street.”
If a child will be required to take a lunch to school, a parent can introduce this new
experience by preparing a bagged lunch at home. If a child is to purchase lunch at
school, the parent can play “cafeteria” at home by serving a buffet-style meal and letting
the child practice walking from one dish to another to select food.
Some kindergartens suggest that children should know how to tie their shoes, name
basic colors, and print their name before they begin. Parents should familiarize
themselves with any such suggestions from the school, but the wisdom of requiring
these skills can be questioned. Identifying colors should be established by this age, but
some children are not coordinated enough at 4 to 5 years of age to tie their shoes or to
print. A better contribution for parents to make toward their children’s achievement in
school is to instill in their children the concept that learning is fun, and that their child
may not always be able to do all the things other children can do, but trying to do one’s
best is what is important. Trying to make children complete fine motor tasks for which
they are not developmentally prepared does not instill that concept.
For children to do well in a formal school setting, they must be able to follow
instructions and sit at a table and chair for a short work period. When some parents
examine their child’s day, they are surprised to realize how few instructions they give
the child in a day. They put on the child’s coat, pick up the child’s toys, and lead the
child to the table for dinner. Similarly, they never encourage their child to spend any
time in a chair, which is something the child will have to do for at least short periods in
school. Coloring at a table rather than on the floor will introduce this situation without
any problem.
Finally, going to school is a form of separation and a new experience if a child has
not attended child care or preschool, so parents must make preparations for this. It might
be good to arrange to have a child stay with another caregiver such as a grandparent for
part of a day. Staying at school can then be compared with that successful event.
These are minimum preparations parents can complete to ready their child for
school. Caution both parents and children that no matter how hard they try, not
everything can be anticipated; school will bring some new happenings that are not
expected. If a child has been led to believe learning is fun and new experiences are
enjoyable (creating a strong sense of initiative), solving these unpredictable problems is
good preparation for the thousands of surprise experiences ahead.
Broken Fluency
Developing language is such a complicated process that children from 2 to 6 years of
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age typically have some speech difficulty. A child may begin to repeat words or
syllables, saying, “I-I-I want a n-n-new spoon-spoon-spoon.” This is called broken
fluency (repetition and prolongation of sounds, syllables, and words). It is often referred
to as secondary stuttering because the child began to speak without this problem and
then, during the preschool years, develops it. Unlike the adult who stutters, children are
unaware that they are not being fluent unless it is called to their attention. You may
need to remind parents that this is a part of normal development and, if accepted as
such, will pass (Nippold & Packman, 2012). It is resolved most quickly if parents
follow a few simple rules, including:
• Do not discuss in the child’s presence that he or she is having difficulty with
speech because this can make the child conscious of speech patterns and
compound the problem.
• Listen with patience rather than interrupt or ask the child to speak more slowly or
to start over. These actions make the child aware speech is repetitious, and
broken fluency increases.
• Always talk to the child in a calm, simple way to role model slow speech. If
adults talk quickly, the child imitates this pattern and has difficulty speaking
clearly.
• Protect space for the child to talk if there are other children in the family.
Rushing to say something before a second child interrupts is the same as rushing
to conform to adult speech.
• Do not force a child to speak if he or she does not want to. Do not ask
preschoolers to recite or sing for strangers.
• Do not reward a child for fluent speech or punish for nonfluent speech. Broken
fluency is a developmental stage in language formation, not an indication of
regression or a chronic speech pattern.
“Bathroom Language”
Many preschoolers imitate the vocabularies of their parents or older children in the
family so well during this time that they incorporate swear words into their vocabularies
if they hear these used. Parents may have to be reminded that children do not
necessarily understand what the word they are using means; they have simply heard it,
just as they have heard hundreds of other words and have decided to use it. Correction
should be unemotional such as, “That’s not a word I like to hear you say. When you’re
angry, why don’t you say ‘fudge’ [or whatever]?” The correcting is no different from
that involved when a child uses poor grammar. If parents become emotional, a child
realizes the value of such a word and may continue using it for the attention it creates.
CONCERNS OF THE FAMILY WITH A PRESCHOOLER WITH

UNIQUE NEEDS
Learning how to do things when you have physical or cognitive limitations can be very
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frustrating. A preschooler with a disability has a greater need for problem-solving skills
than the average child because even simple procedures such as eating or getting dressed
can be difficult if their physical challenge limits the options (see Chapter 54).
Physically challenged or chronically ill preschoolers should attend a preschool
program if at all possible because of the socialization benefits. If a child must remain in
bed, parents may be reluctant to offer potentially messy experiences like finger paint. A
large tray of dry oatmeal or other breakfast cereal with sand shovels or cars and trucks is
a neater substitute activity for such a child. Although not necessarily tidy, these
substances (which are available even in a hospital setting) can be vacuumed away easily
at the finish of play. Table 31.5 lists nursing actions that can aid a chronically
challenged child to solve problems and develop a sense of initiative.
TABLE 31.5 NURSING INTERVENTIONS TO ENCOURAGE A SENSE OF

INITIATIVE IN THE PRESCHOOLER WITH SPECIAL NEEDS
Consideration Nursing Actions
Nutrition Serving toast or sandwiches cut into animal shapes with cookie
cutters, cereal in the form of alphabet characters, or food arranged
on a plate to make a face appeals to the imagination and may make
a preschooler with a limited appetite more interested in eating.
Respect the child’s food preferences because trying to eat a
nonfavorite food is difficult for everyone.
Dressing Allow preschoolers to measure and cut tape or draw a face on it.
changes Allow child to see the incision site. Explain the steps of dressing
change as you work to reduce unknowns and areas of fear.
Provide extra bandages to put on a doll so the child can see that
bandages are not to be feared.
Medicine Allow the child to choose a “chaser” such as juice or milk after oral
medicine.
Choosing a site for injection or intravenous line is too advanced for
the preschooler; do not suggest such choices.
Rest Provide a light in the room or bring the child’s bed into the hallway
so fear of the dark is reduced and the child can deal solely with
problems based in the real world.
Identify sounds the preschooler might hear in the hospital, such as an
air conditioner turning on, and explain what these are.
Hygiene Allow the child to choose bathtub toys and clothing to wear after a
bath.
Allow the child to wash his or her own hands and face.
Allow the child to splash in water as a play activity as well as for
cleanliness.
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Pain Encourage the preschooler to express pain.
Allow the child to handle a syringe or suction catheter, and give
“shots” or suction to a doll to alleviate anger or fear.
Encourage the child to ask for analgesic if necessary.
Stimulation Guessing games encourage a sense of initiative. Draw a dog or a
house and ask the child to close his or her eyes while you add one
more detail to the drawing, such as an ear or a chimney, then ask
the child to identify the new item. Reverse the game and ask the
child what you erased from the drawing, or allow the child to do
his or her own drawing.
Provide manipulative toys, such as finger paint, soapy water, clay, or
dry cereal to use as sand.
Allow the preschooler to accompany you to other departments is a
way of teaching more about the hospital.
Use “Simon Says” games not only for socialization but also to urge
treatments, such as deep-breathing exercises.
Encourage use of the playroom for socialization.
Encourage the child to interact with his or her family by drawing
pictures for siblings or telephoning home.
Nutrition and the Preschooler With Special Needs

Experiences with eating help to reinforce a sense of initiative in preschoolers.
Chronically ill preschoolers who are limited in the foods they can eat (e.g., perhaps they
can eat only soft foods) or in their ability to help with food preparation may miss this
reinforcement. If their appetite is diminished because of illness to the point where they
take little or nothing orally, it is still important that they continue to join the family at
meals if at all possible. In most households, this is a time for socialization, and
preschoolers are ripe for the learning that goes with this type of daily interaction.
What If . . . 31.4
The nurse is particularly interested in exploring one of the 2020 National
Health Goals with respect to preschool growth and development (see Box 31.1).
What would be a possible research topic to explore pertinent to this goal that
would be applicable to Cathy’s family and that would also advance evidence-
based practice?
Unfolding Patient Stories: Jackson Webber • Part 1
Jackson Webber, age 3, is diagnosed with generalized seizures and started on

phenobarbital. His mother is single and employed full time. The mother is concerned
1866
about his recent developmental regression and how that will affect his
return to child care. What education can the nurse provide on normal
growth and development for a 3 year old and the relationship between
developmental milestones and the new onset of an illness? What
questions can the nurse ask to evaluate the adequacy and safety of the child care
center that Jackson attends when considering his new diagnosis of seizures? (Jackson
Webber’s story continues in Chapter 49.)
Care for Jackson and other patients in a realistic virtual environment:
(thepoint.lww.com/vSimMaternityPed). Practice documenting these patients’ care in
DocuCare (thepoint.lww.com/DocuCareEHR).
KEY POINTS FOR REVIEW

Although preschoolers grow only slightly and gain just a little weight, they seem
much taller than when they were toddlers because their contour changes to more
childlike proportions.
Erikson’s developmental task for the preschool period is to gain a sense of initiative
versus guilt, or to learn how to do things. Play materials ideal for this age group are
those that stimulate creativity, such as modeling clay or colored markers.
Promoting childhood safety is a major role because preschoolers’ active
imaginations can lead them into dangerous situations; stressing this helps in planning
nursing care that not only meets QSEN competencies but that also best meets a
family’s total needs.
Common parental concerns during the preschool period are broken fluency,
imaginary friends, difficulty sharing, and sibling rivalry. Preschoolers may develop a
number of universal fears, such as fear of the dark, mutilation, and abandonment.
The preschool age is often the time when a new sibling is born. Helping parents offer
good preparation for this is necessary to prevent intense sibling rivalry.
Preschoolers are still operating at a cognitive level that prevents them from
understanding conservation (objects have not changed substance even if they have
changed appearance).
Preschoolers are self-centered (egocentric) so it is difficult for them to share and
view someone else’s side of a problem. They need good explanations of how a
procedure will benefit them before they can agree to it.
Many preschoolers begin preschool programs or child care. Late in the preschool
period, they may be enrolled in kindergarten. Parents often appreciate guidance on
how to prepare their children for these new experiences.
Preschoolers who have special needs may have difficulty achieving a sense of
initiative because they may be limited in their ability to participate in activities that
stimulate initiative. They may need special playtimes set aside for stimulation and
learning.
1867

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31

Nursing Care of a Family With a

Is Cathy’s father describing typical preschool behavior, or does Cathy need a

Nursing Process Overview

Nursing Assessment of a Preschooler’s Growth and

APPEARANCE OF THE AVERAGE PRESCHOOLER

Weight, Height, Body Mass Index, and Head Circumference

Figure 31.1 Preschoolers like to imitate the roles of adults as they

TABLE 31.1 SUMMARY OF PRESCHOOL GROWTH AND DEVELOPMENT

QSEN Checkpoint Question 31.1

Oedipus and Electra Complexes

Moral and Spiritual Development

Planning and Implementation for the Health Promotion of

PROMOTING PRESCHOOLER SAFETY

COMMON SAFETY MEASURES TO PREVENT UNINTENTIONAL

Keeping Children Safe, Strong, and Free

Motor Vehicle and Bicycle Safety

PROMOTING THE NUTRITIONAL HEALTH OF A PRESCHOOLER

Preschool Nutrition Requirements

PROMOTING THE DEVELOPMENT OF THE PRESCHOOLER IN

QSEN Checkpoint Question 31.2

PROMOTING HEALTHY FAMILY FUNCTIONING

Common Health Problems of the Preschooler

TABLE 31.2 HEALTH MAINTENANCE SCHEDULE, PRESCHOOL PERIOD

TABLE 31.3 PARENTAL DIFFICULTIES EVALUATING HEALTH

Common Fears of the Preschooler

Fear of the Dark

Figure 31.4 Having mom close by after a bad dream is a comfort to a

QSEN Checkpoint Question 31.3

Fear of Separation or Abandonment

Telling Tall Tales

QSEN Checkpoint Question 31.4

Preparing for a New Sibling

Concept Mastery Alert

QSEN Checkpoint Question 31.5

Choosing a Preschool or Child Care Center

TABLE 31.4 QUESTIONS TO USE IN EVALUATING CHILD CARE CENTERS

Preparing a Child for School

CONCERNS OF THE FAMILY WITH A PRESCHOOLER WITH

TABLE 31.5 NURSING INTERVENTIONS TO ENCOURAGE A SENSE OF

Nutrition and the Preschooler With Special Needs

Unfolding Patient Stories: Jackson Webber • Part 1

Jackson Webber, age 3, is diagnosed with generalized seizures and started on

KEY POINTS FOR REVIEW

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