Chapter 16: The Preschool Child: Growth & Nursing Care

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Hello and welcome back to the Deep Dive.

If you are joining us for the first time, this is the place where we try to take some of the heavy lifting out of your study sessions.

We do indeed.

We crack open the textbooks, we sift through all those dense paragraphs, and we really try to extract the absolute gold for you.

Today, we are settling in for a really comprehensive session.

We are taking a stack of source material, specifically from Leifers Introduction to Maternity and Pediatric Nursing in Canada, and we're going to dissect it, analyze it, and hopefully turn it into something you can actually use.

And today's focus is extremely specific, but I would argue incredibly entertaining.

We are looking at Chapter 16, The Preschool Child.

Just to orient everyone on the timeline here, we are leaving the toddler years in the rearview mirror.

Goodbye to the terrible twos, hopefully.

And we are looking at that fascinating window between the ages of three and five.

Ages three to five.

It's a short window, really just a couple of years, but the amount of change that happens here is staggering.

If you are a nursing student or just someone interested in human development, this is where the child really transforms from a baby into a little person.

It's the transition from diapers to backpacks, basically.

Exactly.

And the mission for us today is to guide you through all the developmental nuances of this age group.

We are going to cover everything the text covers, and we're going to stick strictly to the text progression, just to make sure you have a really solid foundation.

So what's on the docket?

We'll look at physical growth, the massive cognitive shifts in how they see the world, which is very different from how we see it, clinical guidance for parents,

safety, and of course, the nursing implications.

Okay, so before we dive into the stats and all the figures, let's define our terms.

When Lifer talks about the preschool child,

what age range are we strictly talking about?

We are defining the preschool period as ages three to five years.

Three to five.

Got it.

And if I had to summarize this stage in one big picture headline, what would it be?

Oh, that's a good question.

The headline is physical growth slows down, but skill mastery speeds up.

Okay, elaborate on that a little bit.

Well, think about infancy.

In the first year of life, the body is growing at an exponential rate.

It's just, it's explosive.

In the preschool years, the body stabilizes.

That growth curve flattens out a bit, but all that energy that was going into just growing the body, it shifts.

It gets redirected toward mastering motor skills, social skills, and cognitive abilities.

So the hardware upgrades slow down, but the software upgrades go through the roof.

That is a perfect analogy.

Yes.

And the major tasks for this age group, they really reflect that shift.

They are preparing for school entry, which is a huge social milestone.

Huge.

They are developing cooperative play.

So learning to play with others, not just next to them.

That's a big jump.

It is.

They are also beating full control of body functions.

Which means potty training is hopefully wrapping up by this point.

Ideally, yes.

They are also working on accepting separation.

This is the age where they learn they can be away from mom or dad and, you know, still be okay.

Right.

And finally, they are drastically improving their communication, memory, and attention span.

Okay, let's get into the weeds then.

Section one, physical and cognitive development.

You mentioned physical growth slows.

Give us the numbers.

How does that actually look?

Let's start with weight.

The text gives us a really useful mathematical benchmark to help you remember this.

So think back to the infant.

We know, based on previous chapters, that an infant triples their birth weight by age one.

Right, rapid growth.

While the preschooler takes that one -year weight and doubles it by age five.

Okay, let me do the math here in my head.

So let's say I have a baby who weighed, I don't know,

nine kilograms at their first birthday.

Okay, nine kilograms.

By the time they blow out the candles on their fifth birthday, you would expect them to be roughly 18 kilograms.

Correct.

Now think about that pace for a second.

It took one year to reach that first nine kilograms.

Yeah.

It takes four more years from age one to age five to gain the next nine kilograms.

That really illustrates the breaking mechanism on physical growth.

It's a steady, much slower climb.

That's a great way to visualize it.

What about height?

Height increases by about 7 .5 centimeters per year between ages three and five.

But what is medically interesting here is where that growth happens.

Oh, yeah.

It's mostly in leg length.

So their proportions change.

Drastically.

You lose that classic toddler chubbiness,

the pot belly disappears, the sway back, you know that condition called lordosis that makes toddlers walk with their belly out?

Yeah.

That goes away.

They develop a more slender, erect appearance.

We start looking like miniature adults rather than, you know, babies.

Exactly.

And their movement changes too.

Their gait becomes much more adult -like.

They aren't toddling anymore.

They can swing their arms.

They can jump higher.

They are quicker and have way more self -confidence in their bodies.

Let's run through the vital signs.

If I'm a nursing student doing a rotation in a pediatric clinic, what numbers am I looking for on the chart for this age group?

Okay, let's break it down.

For a preschooler, the normal pulse rate is somewhere between 65 to 110 beats per minute.

So slightly slower than a toddler, but still a lot faster than an adult.

Right.

For respiration, you are looking at about 20 to 25 breaths per minute during relaxation.

Okay.

And for blood pressure, the normal range is a systolic of 95 to 110 and a diastolic of 60 to 75.

What about vision?

I recall from the reading that their vision isn't fully mature yet at this stage.

No, not quite.

At age three, visual acuity is typically around 20 -40.

Okay.

By age four, it sharpens to 20 -30.

We usually don't see that perfect 20 -20 vision until they're school -aged, but this is a really critical time for screening to catch any issues like amblyopia early on.

And teeth.

What's happening there?

By this stage, all 20 primary teeth, the deciduous teeth, have erupted.

So dental hygiene becomes very, very real.

Now, here's a point from the text I found really important for parents and educators, and frankly, for nurses giving advice.

Hand preference.

Yes.

This is a big one.

Hand preference, being left or right -handed, usually develops by age three.

And the text has a very specific warning here.

Do not force a change.

So if my child is using their left hand to color,

I shouldn't try to nudge them to switch to the right.

Absolutely not.

And historically, this was something people tried to do, you know?

Right.

But Lifer is very clear.

Efforts to change a child's handedness can cause a high level of

It's a neurological wiring issue, not a bad habit.

I see.

You have to let them use the hand they prefer.

It's about brain development, not manners.

That's really good to know.

Okay, let's shift gears to what is arguably the most entertaining part of this age group.

Their cognitive development.

How do they think?

Because talking to a four -year -old is a trip.

It certainly is.

This brings us to the work of Jean Piaget.

According to Piaget, the preschool child is in the preoperational phase.

Okay, preoperational.

What are the boundaries of that?

When does it start and end?

This phase covers ages two to seven, but the text divides it further into two parts.

The pre -conceptual stage, which is ages two to four, and the intuitive thought stage from ages four to seven.

Okay, let's start with the pre -conceptual stage then.

Ages two to four.

What defines this period?

The big development here is something called symbolic functioning.

This is the ability to create a mental image for something that isn't physically present.

Can you give me an example of that?

Sure.

The classic example is the empty cardboard box.

Okay.

To an adult, it's a shipping container.

But to a child with symbolic functioning, that box is a fort,

or a spaceship, or a race car.

They can look at an object and mentally assign it a whole different function or identity.

It's really the birth of true imagination.

But there are limitations, right?

They aren't just mini geniuses running around.

Right.

The biggest limitation is egocentrism.

Now, we need to clarify this because egocentric sounds like an insult in adult language.

If I call you egocentric, I'm saying you're selfish.

True.

But in Piaget's terms, it's not about being selfish or arrogant.

It's about a cognitive inability to see a point of view other than their own.

So they literally think everyone sees what they see.

Yes.

If a child is looking at a toy from one side of the table,

they assume you see the toy in exactly the same way, even if you are standing behind it.

They cannot conceptualize that you have a different perspective.

Is this why they are so bad at hide and seek?

Exactly.

If they cover their eyes and can't see you.

They think you can't see them.

Precisely.

Because their perspective is the only perspective that exists in their world.

That explains so much.

It also leads to some really interesting misconceptions about the world.

The text mentions animism and artificialism.

Yes.

These are great concepts to understand.

Animism is the tendency to attribute life to inanimate objects.

So if a child bumps into a table, they might say, the table is bad, it hit me.

Right.

Or they might whisper, the doll is tired.

They genuinely believe objects have intent and feelings.

And artificialism.

What's that?

Artificialism is the idea that people created the world and everything in it.

They think someone built the mountains with a bulldozer.

Or maybe someone painted the sky blue.

To them, everything is man -made because their world is so controlled and created by the adults around them.

That makes a strange kind of sense.

Okay, so that's preconceptual.

What happens at age four when they hit the intuitive thought stage?

This is where thinking becomes intuitive, but not yet logical.

They base their conclusions on the outside appearance of things rather than on any internal logic.

The classic concept here is centering.

Centering.

Yes.

Centering is the tendency to concentrate on a single outstanding characteristic of an object while completely ignoring everything else about it.

Is this the famous juice glass experiment?

It is.

Exactly.

Imagine you have two identical short wide glasses with the same amount of juice.

The child agrees they are equal.

Okay.

Then you pour the juice from one of those glasses into a tall, thin test tube right in front of them.

The preschooler will insist that the tall tube has more juice.

Why?

They just saw you pour it.

Because they are centering on the height.

They see tall and their brain immediately thinks more.

They cannot simultaneously process the width of the glass to realize the volume is the same.

They lack that concept of conservation of mass.

That is so important for nurses to know.

You can't reason with them using multi -variable logic.

No, you can't.

You have to explain things very simply, focusing on one aspect at a time.

If you try to explain a medical procedure with three different variables, you've completely lost them.

The text provides a fantastic table.

Table 16 .1 that breaks down development year by year.

I want to walk through this because the difference between a three -year -old and a five -year -old is just massive.

It is.

A three -year -old and a five -year -old are practically different species.

Let's start with the three -year -old.

Okay.

Age three.

Intellectually, what are they like?

They're deep in that preoperational phase.

They understand time only in relation to concrete activities.

You can't say, we will go at 1 .0.

You have to say, we will go after lunch.

Their attention span is still pretty short, about 15 minutes.

They are very easily distracted.

Emotionally, how are they doing?

They generally want to please their parents.

This is Erickson's stage of initiative versus guilt.

They are trying to initiate things like dressing themselves, and if they do well, they feel good.

If they are criticized, they feel guilt.

What about play?

It's largely parallel and associative play.

They play near others.

Maybe they'll share a toy, but they aren't organizing a complex game together.

It's highly, highly imaginative.

Okay.

Moving on to the four -year -old.

The text paints a slightly wilder picture here.

Age four is dynamic.

Intellectually, they can count to five.

They know simple songs, but emotionally, they can be a handful.

A handful how?

The text uses words like boisterous.

They have mood swings.

They can be aggressive.

They like to show off their accomplishments.

The look at me, look at me phase.

That's the one.

Sexual curiosity is high at this age.

Their attention span increases a bit, maybe to 20 minutes.

Linguistically, they are using four to five word sentences and have a vocabulary of about 1 ,500 words.

That's a lot of words.

It is.

Finally, the five -year -old.

Age five feels like a settling down.

They are more responsible.

They have a beginning concept of past, present, and future.

They know the days of the week.

They can count to 10, and their attention span hits about 30 minutes.

And socially, how do they change?

They are less egocentric.

They have a beginning awareness of the outside world, of other people's feelings.

They enjoy activities with the parent of the same sex, and in play, they want to play by the rules.

But there's a catch with the rules, right?

I remember reading this.

Yes, there's a big catch.

They cannot accept losing.

They understand the rules exist, but emotionally, they still need to win.

I feel like I know some adults like that.

We all do, but for a five -year -old, it is developmental, not a character flaw.

Okay, fair enough.

Let's move to section two, culture, language, and play.

The text has a specific note on bilingualism that I think is really important, especially given the multicultural nature of Canada.

It does.

Cultural practices vary, of course, but the text emphasizes that children adapt very quickly to a bilingual environment.

Hearing two languages does not delay them.

In fact, mastering sounds proceeds in the same order globally.

It's a strength, not a deficit.

That's great to hear.

Let's talk numbers on language.

We touched on it, but the sentence length rule is really handy for a quick assessment.

It is.

It's a great rule of thumb.

The number of words in a sentence generally equals the child's age.

So a two -year -old says, my ball, two words.

Exactly.

A three -year -old says, I want ball, three words.

By age five, they are using these complex sentences with future tense.

And the vocabulary count.

It just explodes.

At age three, they have roughly 300 to 800 words.

Okay.

By age five, they have 2 ,000 words.

That is a massive data upload in just two years.

Wow.

Now, stuttering.

This is something parents worry about constantly.

It is very common.

The text defines it as a disorder in rhythm, but it's reassuring.

It often improves by school age.

Why does it happen?

It's often a case of the brain working faster than the mouth.

The ideas are coming so fast that the tongue just can't keep up.

The text mentions it improves when talking to pets.

That's interesting.

Yes.

Or singing, because there is less pressure.

When you talk to a dog, you aren't worried about being corrected or judged.

It frees them up.

I want to spend a moment on the clinical tools table 16 .2 and 16 .3.

These seem crucial for nurses to identify red flags for school readiness.

Absolutely.

Table 16 .2 lists processes needed for school.

It's not just about IQ.

It's about specific processing skills.

Okay.

Like what?

For example, visual analysis.

Can the child break a complex figure into its components?

If not, they are going to confuse letters like B, D, and G when they try to read.

I see.

What about proprioception?

That's knowing where your body is in space.

If a child struggles with this, they might have poor handwriting or grasp the pencil way too tight because they can't feel the control they're exerting.

And phonological processing.

That's the ability to break words into sounds.

If this is delayed, they will struggle with reading because they can't map the sound to the letter.

These are the sort of hidden hurdles to education.

Table 16 .3 is the clinical classification of not talking.

I love how practical this is.

It translates common parent complaints into clinical terms.

Let's run through them.

This is triage gold for a clinic nurse.

So if a parent comes in and says, I'm the only one who understands what she says.

That's an articulation disorder.

The speech is there.

It's just not clear.

Exactly.

What if a parent says, she'll do what I say, but when she wants something, she just points.

She won't say the word.

Okay.

So that's an expressive language delay.

Receptive language, their understanding is good, but their expressive language is stuck.

Perfect.

How about this one?

He can't play show me your nose, and the only word he says is mama.

That sounds like a global language delay.

Both receptive and expressive are behind schedule.

And finally, the big warning sign.

He used to say things like, Joey, go bye -bye, but now he doesn't talk at all.

That's language loss.

Exactly.

And any loss of previously acquired skills needs an immediate evaluation.

That is a major neurological red flag.

I don't know.

Let's talk play.

We know play evolves, but let's look at the themes.

How does that change from age three to five?

Well, at two, three years, play is about imitating daily life.

Domestic stuff, shaving like dad, feeding a doll, cooking like mom.

Very concrete.

Very.

By four years, the themes broaden out.

Maybe they act out a trip to the zoo, but by five years, it goes off planet, a trip to the moon.

Wow.

This shows their imagination is no longer tethered to their immediate living room reality.

It's extending.

And screen time.

This is a hot topic for every parent.

It is.

And the Canadian Pediatric Society, or CPS, guidelines cited in the text is pretty strict.

What's the rule?

Limit screen time to one hour per day for ages two to five.

And it should be high quality programs, ideally with parents present and interacting.

Why so strict?

Because passive screen time replaces the active, imaginative play and social interaction that really drives development.

You can't learn social cues from a screen the way you can from another child in the sandbox.

Makes sense.

One note on spiritual development before we move on.

The book touched on this.

It did.

The text notes that preschoolers have a very concrete concept of God, often imagining God like an invisible friend.

And rituals like bedtime prayers can be very comforting for them, especially in the hospital.

It gives them a sense of structure and safety in a scary, unpredictable environment.

Okay.

Section three.

Development through the years.

We are going to zoom in on the personality of each age again, but with a bit more detail on specific behaviors and fears.

Let's look at the three -year -old again.

Right.

So three -year -olds are generally pretty helpful.

They are gaining independence.

They can help dress themselves, use the toilet, wash their hands.

They want to be part of the team.

But they have some very specific fears at this age.

Yes.

The fear of bodily harm is really unique to this stage.

The text mentions that if they discover a sibling is made differently, like a boy seeing a girl in the bath, they might worry that the girl was injured or that something was cut off.

They fear losing body parts.

Yes.

That's a huge one.

If they scrape a knee, they might think all their insides are going to fall out.

They need a band -aid, not just for the bleeding, but to psychologically hold them together.

And they have a romantic attachment to the parent.

What does that mean?

Yes.

This refers to the Oedipus or electro -complex ideas from psychoanalytic theory.

A daughter wanting to marry daddy or a son wanting to marry mom.

Okay.

It's a normal part of development as they start to identify with the same -sex parent and form a strong attachment to the opposite -sex parent.

Now the four -year -old, we said they're boisterous.

They are.

They can be more aggressive.

They tattle on others.

They might pick up profanity and try it out.

But they are also deeply curious about relationships.

They are fascinated that a person can be two things at once, that Jacob is a brother and Edith's son.

They are trying to map out their entire social web.

And they prefer raw materials for play.

I found that interesting.

Yes.

A big cardboard box is way better than a fancy dollhouse.

A box of sand is better than a rigid toy.

They want to build and create.

Rather than just using a toy that does only one thing, it fuels that imagination.

This is also the age of sexual curiosity though.

Where do babies come from?

Yeah.

And why does he look different than me?

Question.

It is.

And the text gives some really clear principles for parents on how to handle this.

What are they?

One, assess what the child is actually asking.

Don't give a whole biology lecture if they just want to know if the baby came from the hospital.

Two, be honest and accurate.

Three, use correct terminology.

And four, answer them immediately.

Don't put it off.

What about masturbation?

That's a topic that makes a lot of parents uncomfortable.

It does, but it's common in both genders at this age.

The text explicitly states it is considered harmless if it's not a preoccupation.

So how should parents handle it?

They should try to ignore the behavior or distract the child.

Do not punish them.

You can explain that it's something that's not for public settings, but you should never shame them for it.

What about the concept of death?

How do they process that?

Well, between ages three and four, they start to wonder about death.

But they see it as temporary, sort of like a cartoon character who gets flattened by an anvil and then just pops back up in the next scene.

So how do you handle it if it comes up?

Be casual.

Reassure them.

People usually live for a very long, long time.

Don't avoid the topic, but don't make it scary.

You don't want them worrying.

You'll vanish forever every time you go to the grocery store.

And finally, the five -year -old.

The five -year -old is more responsible, more patient.

They can finish tasks they start.

Physically, they might begin to lose their baby teeth.

Well, it's a tooth fairy stage.

Exactly.

They can ride a tricycle with speed and skill.

They can use a hammer to pound nails.

They can print their first name.

They're really getting ready for the instruction of school.

OK, let's move to section four.

Guidance, discipline and behavioral issues.

This feels like the section where nurses give advice to exhausted parents.

It is.

And it all starts with the philosophy of discipline.

What is the purpose of discipline, according to the text?

The main purpose is to shift control from the parent to the child.

It's all about teaching self -discipline.

It's not just about stopping bad behavior in the moment.

It's about teaching the child to regulate themselves in the long run.

So what techniques work?

What does the book recommend?

Timeouts are the gold standard mentioned here.

And there's a specific rule.

One minute per year of age.

So a three -year -old gets a three -minute timeout.

Correct.

And the execution of it really matters.

You should use a timer.

So the clock is the bad guy, not the parent.

There should be no interaction or out -contact during the timeout.

If they talk or get up, you restart the timer and you give a brief explanation before and after maximum 10 words.

You hit.

So timeout.

Don't get into a long lecture.

What about spanking?

The text is explicit.

It is discouraged.

It can be physically and psychologically damaging.

It models aggression.

You are literally hitting a child to teach them not to hit.

That's a good point.

And it's often ineffective because the child just focuses on the parent's anger and the pain, not on what they actually did wrong.

Let's clarify rewards versus bribes.

There's a difference.

A huge difference.

A reward is agreed upon before the behavior.

If you clean up your toys, we can go to the park.

That's positive reinforcement.

Okay.

A bribe is offered during bad behavior to make it stop.

Stop crying and I'll give you a cookie.

Bribes just reinforce the bad behavior.

That is a life lesson right there.

What about jealousy and sibling rivalry?

It's normal, but challenging.

The text suggests handling it by preparing the child early for a new sibling,

move them to a big kid bed well before the baby arrives so they don't feel displaced by the new baby in the crib.

That's smart.

And when they fight, you have to give the aggressor as much attention as the victim once they're separated.

If you only comfort the one who got hurt, the other child feels isolated and that just fuels the jealousy.

Thumb sucking.

Should parents worry?

Not really.

It's normal until about age five.

It provides self -consoling.

Parents should be supportive, not anxious about it.

Praise them when they don't do it, but don't turn it into a battle.

An enuresis or bedwetting.

This is a big one.

Yes.

First, you have to classify it.

Primary enuresis means the child has never been consistently dry at night.

Secondary enuresis is when they were dry for a year more and then started wetting the bed again.

Secondary often points to stress.

What are the causes?

It could be a small bladder capacity, very deep sleep, stress, or organic causes like a UTI or even diabetes.

You have to rule out the medical stuff first.

Then treatment.

You start simple.

Limit liquids after dinner.

Make sure they void right before bed.

Conditioning alarms, those moisture -sensitive alarms that wake the child up, are actually the most effective long -term therapy.

Are there medications for it?

There are, but they're used with a lot of caution.

Desmopressin acetate can be used for special occasions like a sleepover or camp, but it requires strict fluid restrictions to avoid the risk of water intoxication.

That sounds serious.

It is.

And another drug, imipramine, is an older one that's rarely used now because of its side effects.

The most important thing really is a non -punitive matter -of -fact attitude.

It's not their fault.

Okay.

Section five, care, safety, and nursing implications.

Let's talk preschool selection.

What should parents look for?

You want to check the licensing, check the staff qualifications, are they trained in early childhood education, check the ratios.

The guideline is about one staff member for every eight children.

You should probably visit first.

Oh, absolutely.

Go observe the indoor and outdoor play environments.

Get a feel for the place.

Accident prevention.

What are the big risks at this age?

They're more mobile now.

They are.

The big risks are falls from things like stairs or climbing trees, burns from matches, lighters, hot liquids, poisoning, often from imitating adults taking pills.

Right.

They see you take a pill and think it's candy.

Exactly.

And strangers.

This is the age to teach them about code words for pickup and not to accept rides or gifts from anyone they don't know.

Let's talk about play in the hospital.

This is a key nursing role.

It is.

The nurse uses play to build rapport and to relieve stress.

It's their work and it's how they process things.

Safety first, though.

Always.

The text gives great examples.

No friction toys near an oxygen tent because of the spark risk.

No stuffed animals for asthmatic children because of dust mites and allergens.

And there are specific types of play mentioned.

Yes.

There's therapeutic play.

This is play that's used to actually achieve a therapeutic goal.

Like what?

For example, having a child blow out a flashlight candle to improve their respiration after surgery.

It's a game to them, but it's actually respiratory therapy.

That's clever.

There is also art therapy to help them express feelings they can't verbalize.

And play therapy, which is a more formal psychological technique used by trained therapists to work through trauma or stress.

And finally, let's wrap this all up with nursing implications.

How do we care for these kids in a hospital setting, keeping everything we've discussed in mind?

Okay, so nutrition.

Don't force feed.

Their appetites fluctuate wildly.

Making it a power struggle helps no one.

Safety is a given.

Childproof everything.

But the emotional care is where it gets complex.

I hope so.

You have to remember, they think magically.

They often view hospitalization as a punishment.

I was bad, so I got sick.

You have to constantly reassure them that they aren't being punished.

And you have to expect a certain reaction to being there.

Absolutely.

Expect separation anxiety, the stages of protest, despair, and detachment.

And expect regression.

A five -year -old who has been toilet trained for years might start wetting the bed again.

That is all normal.

It's a stress response.

This has been a massive download of information.

It has.

But if you take one thing away from all this, it's that the preschool child is a complete work in progress.

They are physically slowing down.

But mentally and socially, they are just sprinting.

They are figuring out the rules.

They're testing all the boundaries.

And they're building the foundation for the person they're going to become.

Exactly.

And as nurses, our job is to guide them and their parents through that process as safely and supportively as we can.

Thank you for joining us on this deep dive into Lifer's Chapter 16.

Happy studying!

This is the Last Minute Lecture Team signing off.