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. 87 lb is a reasonable weight for a 10-year-old boy who was 80 lb the previous year, considering the average weight gain is about 10 pounds a year at this age.
B. 81 lb would be a below-average weight gain for a year for a child of this age. C. 89 lb would be an above-average weight gain for a year for a child of this age.
D. 85 lb is within the range but slightly below the average expected weight gain for a year for a child of this age.
Correct Answer is C
Explanation
A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.
B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.
C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.
D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding
patterns before discussing solid food introduction.
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