The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
“This is a vasomotor response caused by cooling or warming."
“This is normal her circulatory system will take a few days to adjust.”
"Let's watch her carefully to make sure she does not have a circulatory problem."
"Your daughter has acrocyanosis; this is causing her blue hands and feet.”
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Height in girls increases rapidly after menarche and usually ceases immediately after
menarchE. Height increases during adolescence are not directly related to menarche. Growth in girls typically continues for several years after menarche, although at a slower rate compared to the pre-pubertal growth spurt.
B. Boys' growth spurts usually begin between the ages of 8 and 14 years and end between the ages of 13½ and 17½ years: While boys do experience a growth spurt during adolescence, the timing and duration of growth spurts can vary widely among individuals. Growth typically
continues beyond the age of 14, with some boys reaching their full adult height in their late teens or early twenties.
C. Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarchE. Peak height velocity refers to the period of most rapid growth during adolescence. In girls, PHV typically occurs around the age of 12, with growth continuing for some time after menarche.
D. Boys reach PHV and peak weight velocity (PWV) at about 16 years of agE. Boys generally experience PHV and PWV later than girls, typically occurring around the age of 14 to 16. These milestones mark the period of most rapid growth in boys, with height and weight increasing significantly during this time.
Correct Answer is B
Explanation
A. Menarche
Menarche refers to the onset of menstruation, typically occurring around 12 to 13 years of age, although it can vary widely.
B. Thelarche
Thelarche is the development of breast buds, which usually occurs around 8 to 13 years of age in girls, marking the beginning of breast development and the first sign of puberty.
C. Tanner stage 5
Tanner stage 5 refers to the final stage of sexual maturity in the Tanner Scale, characterized by adult breast development and pubic hair distribution. It is not typically used to describe the initial appearance of breast buds.
D. Puberty
Puberty is the period of development during which sexual maturity is attained, including physical changes such as growth spurts, development of secondary sexual characteristics, and
reproductive capacity. Thelarche is an early sign of puberty, but it does not encompass the entire puberty process.
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