A 14-year-old female client comes into the clinic for an annual exam and expresses concern about not starting her menstrual cycle. Which finding should the nurse recognize as potential cause of delayed menstration?
Reference Range: Hemoglobin [10 to 15.5 g/dL (100 to 155 g/L)]
Family history of breast cancer.
Tanner stage 2 of breast development.
Hemoglobin of 10 g/dL (100 g/L).
Low body mass index (BMI).
The Correct Answer is D
Rationale:
A. Family history of breast cancer: While a family history of breast cancer is important for long-term health risk assessment, it does not directly affect the timing of menarche or cause delayed menstruation in adolescents.
B. Tanner stage 2 of breast development: Tanner stage 2 indicates early pubertal development, which is typical for girls approaching menarche. Although this shows puberty has begun, it is not itself a cause of delayed menstruation.
C. Hemoglobin of 10 g/dL (100 g/L): A hemoglobin level of 10 g/dL represents mild anemia, which may affect overall health but is not usually sufficient alone to delay the onset of menstruation.
D. Low body mass index (BMI): A low BMI can result in insufficient body fat necessary for the hormonal regulation of menstruation. Adolescents with low BMI may experience delayed menarche due to decreased estrogen production and energy availability required for the onset of ovulatory cycles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Contact the healthcare provider: Notifying the provider is important if meconium-stained fluid is present, but immediate assessment of fetal well-being takes priority before contacting the provider.
B. Assess the fetal heart rate (FHR): The presence of greenish-brown amniotic fluid indicates possible meconium-stained fluid, which can signal fetal distress. Assessing the FHR first allows the nurse to determine if the fetus is currently compromised and requires urgent intervention.
C. Check the cervical dilation: Cervical assessment provides information about labor progression but does not address the immediate concern of potential fetal compromise from meconium aspiration.
D. Turn the client to her left side: Positioning can improve uteroplacental perfusion if the fetus is distressed, but the first step is to assess the FHR to identify any current compromise before implementing interventions.
Correct Answer is B
Explanation
Rationale:
A. Monitor the stool and urine output of the neonate for the last 24 hours: Monitoring elimination patterns is important to assess hydration and feeding adequacy. However, a weight loss of approximately 6% from birth is within the expected physiologic range and does not require immediate intervention.
B. Inform and assure the mother that this is a normal weight loss: Newborns typically lose 5–10% of their birth weight during the first 3–5 days due to fluid shifts and limited initial intake. The nurse’s priority is to reassure the mother, explain that this is expected, and continue supporting regular feeding.
C. After verifying the accuracy of the weight, notify the healthcare provider: Notifying the healthcare provider is necessary if the weight loss exceeds 10% of birth weight or if there are signs of dehydration. In this case, the loss is within the normal range.
D. Encourage the mother to increase frequency of breastfeeding: Increasing feeding frequency is important if the infant shows inadequate intake or excessive weight loss. Since the weight loss is physiologic and expected, routine feeding patterns can continue.
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