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 D
Explanation
A. Substituting cow's milk if breast milk is not availablE. Cow's milk is not recommended as a substitute for breast milk or infant formula for infants under 12 months old due to its low iron content and potential for causing gastrointestinal irritation.
B. Advising fluid intake per feeding of 5 or 6 ounces: The appropriate fluid intake for a 2-week- old infant is typically guided by feeding cues and may vary from feeding to feeding. Providing a specific volume of fluid per feeding may not be appropriate, as infants should be fed on demand.
C. Advocating iron supplements with bottle-feeding: Iron supplementation is generally recommended for breastfed infants starting at around 4 months of age, but it is not typically necessary for formula-fed infants during the first few weeks of life. Additionally, iron
supplementation should be prescribed and monitored by a healthcare provider rather than advocated as a general guideline.
D. Discouraging the addition of fruit juice to the diet: This is the most effective anticipatory guidance because it aligns with current recommendations from pediatric healthcare
organizations. Fruit juice offers little nutritional value for infants and can contribute to dental caries and excessive calorie intake. It is generally recommended to avoid giving fruit juice to infants under 1 year old.
Correct Answer is ["90"]
Explanation
Answer: 90beats per minute
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