A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?
Assess for presence of a supernumerary breast nipple.
Use the Tanner staging to determine sexual maturity.
Palpate for evidence of temporary gynecomastia.
Calculate approximate age menstruation should occur.
The Correct Answer is B
Choice A reason: Assessing for presence of a supernumerary breast nipple is not a relevant technique to determine if the client has reached the age of menarche. A supernumerary breast nipple is an extra nipple that develops along the embryonic milk line, usually in the chest or abdomen. It is a congenital anomaly that affects about 1% to 5% of the population, and it has no relation to the onset of menstruation.
Choice B reason: Using the Tanner staging to determine sexual maturity is a valid technique to determine if the client has reached the age of menarche. The Tanner staging is a scale that assesses the development of secondary sexual characteristics, such as breast growth, pubic hair growth, and genital development, in relation to the chronological age of the child. The Tanner staging can help estimate the stage of puberty and the likelihood of menarche, which usually occurs around Tanner stage 3 or 4 in girls.
Choice C reason: Palpating for evidence of temporary gynecomastia is not an appropriate technique to determine if the client has reached the age of menarche. Gynecomastia is the enlargement of breast tissue in males, due to hormonal imbalance, medication side effects, or other causes. It is a common condition that affects up to 70% of adolescent boys, and it usually resolves spontaneously within a few months or years. Gynecomastia has no relevance to the onset of menstruation in girls.
Choice D reason: Calculating approximate age menstruation should occur is not a reliable technique to determine if the client has reached the age of menarche. The age of menarche varies widely among individuals, depending on genetic, environmental, nutritional, and psychosocial factors. The average age of menarche in the United States is about 12.5 years, but it can range from 8 to 16 years. Therefore, calculating the approximate age of menarche based on averages or norms may not reflect the actual situation of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Instructing the mother to feed the infant nothing for 30 minutes after giving the iron drops is not a correct intervention. It may cause the infant to become hungry, fussy, or dehydrated. It may also interfere with the absorption of iron, as food can enhance the bioavailability of iron in the body.
Choice B reason: Suggesting placing the iron drops in the orange juice and then feeding the infant is not a correct intervention. It may alter the taste and color of the orange juice, making it less palatable for the infant. It may also reduce the potency of the iron drops, as iron can react with the citric acid and vitamin C in the orange juice and form insoluble complexes.
Choice C reason: Telling the mother to follow the iron drops with infant formula instead of orange juice is not a correct intervention. It may decrease the absorption of iron, as calcium and casein in the infant formula can bind with iron and form insoluble complexes. It may also increase the risk of gastrointestinal side effects, such as constipation, nausea, or vomiting.
Choice D reason: Giving the mother positive feedback about the way she administered the medication is a correct intervention. It reinforces the mother's behavior and encourages her to continue giving the iron drops as prescribed. It also acknowledges the mother's efforts and shows respect and appreciation. Following the iron drops with orange juice is a good practice, as vitamin C in the orange juice can enhance the absorption of iron in the body.
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
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