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 D
Explanation
A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.
B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the
thermometer in their mouth.
C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic
measurements or when rectal measurement is contraindicated.
D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.
However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.
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