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 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
Correct Answer is A
Explanation
Choice A reason: Flaring of the nares is a sign of acute respiratory distress in children. It indicates that the child is using the accessory muscles of the nose to breathe, which is a sign of increased work of breathing. Flaring of the nares may be accompanied by other signs of respiratory distress, such as retractions, grunting, or cyanosis. The nurse should report this finding to the health care provider and monitor the child's oxygen saturation, respiratory rate, and level of consciousness.
Choice B reason: Diaphragmatic respirations are not a specific sign of acute respiratory distress in children. They are a normal pattern of breathing in infants and young children, who use their diaphragm more than their chest muscles to breathe. Diaphragmatic respirations may become more pronounced when the child is crying, feeding, or sleeping, but they are not indicative of respiratory distress.
Choice C reason: A resting respiratory rate of 35 breaths/min is not a sign of acute respiratory distress in children. It is within the normal range for a 1-year-old child, who typically has a respiratory rate of 20 to 40 breaths/min. A resting respiratory rate of more than 60 breaths/min may be a sign of respiratory distress in children, especially if it is associated with other symptoms, such as wheezing, coughing, or nasal flaring.
Choice D reason: Bilateral bronchial breath sounds are not a sign of acute respiratory distress in children. They are normal breath sounds that are heard over the trachea and the large bronchi. They are loud and high-pitched, and have a longer expiratory phase than inspiratory phase. Bilateral bronchial breath sounds do not indicate any lung pathology or obstruction.
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