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 A
Explanation
A. Do nothing: this is a normal condition for toddlers: Lordosis, also known as swayback, is a common and typically normal finding in toddlers as they develop and their posture adjusts. It is characterized by an exaggerated curvature of the lumbar spine. In most cases, lordosis resolves on its own as the child grows and their musculoskeletal system matures. Therefore, no
intervention is usually necessary.
B. Notify the primary care healthcare provider about the condition: Lordosis alone is not
typically considered a concerning finding in toddlers unless it is severe or accompanied by other
symptoms. It is not necessary to notify the primary care provider unless there are additional concerning signs or symptoms.
C. Refer the toddler to a physical therapist: Referring the toddler to a physical therapist for lordosis alone is not warranted unless there are other significant musculoskeletal issues or developmental concerns.
D. Explain that the child will need a back bracE. Lordosis in toddlers does not typically require the use of a back brace. It is usually a benign and self-limiting condition that resolves with time as the child's musculoskeletal system matures.
Correct Answer is B
Explanation
A. Maximizing learning potential: While education is important during adolescence, the priority focus of guidance regarding healthy lifestyles typically centers around behaviors that directly
impact physical and emotional well-being.
B. Reducing risk-taking behavior: Adolescents are prone to engaging in risky behaviors such as substance use, unsafe sexual practices, and reckless driving. Guidance should emphasize
strategies to reduce these behaviors and promote safer choices.
C. Promoting adequate physical growth: Physical growth is largely determined by genetics and occurs earlier in life. While maintaining overall health, including physical activity and nutrition, is important during adolescence, it is not typically the primary focus of guidance regarding
healthy lifestyles at this stage.
D. Teaching personal hygiene routines: Personal hygiene is important for overall health, but it is just one aspect of a healthy lifestyle. While adolescents should be encouraged to practice good hygiene habits, guidance should encompass a broader range of behaviors that contribute to overall well-being, including mental health and risk reduction.
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