The nurse is performing an assessment of the reproductive system of a 17-year-old girl. What would alert the nurse to a developmental delay in this girl?
Areola and papilla separate from the contour of the breast
Absence of first menstrual period
Developed breast tissue
Mature distribution and coarseness of pubic hair
The Correct Answer is B
A. Areola and papilla separate from the contour of the breast: This is a normal finding in breast development and indicates Tanner stage 4 or higher, which is typical for adolescent girls. It does not necessarily indicate a developmental delay.
B. Absence of first menstrual perioD. Menarche, the first menstrual period, typically occurs between the ages of 9 and 15 in girls. Absence of menarche by the age of 15 or within 3 years after the onset of breast development (thelarche) may indicate a developmental delay or underlying medical condition that should be evaluated by a healthcare provider.
C. Developed breast tissuE. Breast development, indicated by palpable breast tissue, is a normal part of female puberty and typically occurs before menarche. Developed breast tissue alone does not necessarily indicate a developmental delay.
D. Mature distribution and coarseness of pubic hair: Pubic hair development is also a part of female puberty and occurs before or around the time of menarche. While the distribution and coarseness of pubic hair can provide information about pubertal development, the absence of menarche is a more reliable indicator of a potential developmental delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The child does not vocally respond to voices: While vocal responsiveness is an important aspect of development, it may vary among infants and is not necessarily indicative of a developmental problem at 4 months.
B. The child never squeals or yells: Squealing and yelling are vocalizations that infants may or may not exhibit at this age, and their absence alone may not necessarily indicate a developmental problem.
C. The child does not babblE. Babbling, which typically begins around 4 to 6 months of age, involves the repetition of consonant-vowel combinations (e.g., "bababa"). The absence of babbling by 4 months may suggest a delay in language development and could be a potential sign of a developmental problem.
D. The child does not say dada or mamA. Infants may begin to associate "dada" or "mama" with specific caregivers, but this typically occurs later, closer to 6 to 9 months of age. The absence of this behavior at 4 months may not necessarily indicate a developmental problem.
Correct Answer is D
Explanation
A. “This is a vasomotor response caused by cooling or warming": While vasomotor responses can cause changes in skin color due to temperature changes, acrocyanosis specifically refers to blue discoloration of the hands and feet due to reduced peripheral circulation, not necessarily due to temperature changes.
B. “This is normal her circulatory system will take a few days to adjust”: While it's true that newborns may have transient circulatory changes as their circulatory system adapts after birth, acrocyanosis specifically refers to a benign condition characterized by persistent blue discoloration of the extremities unrelated to circulatory adjustments.
C. "Let's watch her carefully to make sure she does not have a circulatory problem": While it's important to monitor infants for any signs of circulatory problems, acrocyanosis is typically a
benign and self-limiting condition that does not require intervention unless accompanied by other concerning symptoms.
D. "Your daughter has acrocyanosis; this is causing her blue hands and feet.”: This response provides an accurate explanation for the blue discoloration of the infant's hands and feet. Acrocyanosis is a common and benign condition in newborns characterized by blue discoloration of the extremities due to peripheral vasoconstriction, which gradually resolves over the first few days to weeks of life.
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