A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation?

"This is normal behavior for infants unless the stool passed is black or green."

"This is normal behavior for infants due to the immaturity of the gastrointestinal system."

"This is normal behavior for infants unless the stool passed is hard and dry."

"This indicates a blockage in the intestine and must be reported to the health care provider."

Answer and Explanation

The Correct Answer is B

A. "This is normal behavior for infants unless the stool passed is black or green.": While black or green stools may indicate potential issues, grunting and crying during bowel movements are common behaviors in infants and are not necessarily indicative of a problem.

B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system.": Grunting and crying during bowel movements are typical behaviors in infants, especially during the first few months of life. This is because the infant's gastrointestinal system is still developing and they may have difficulty coordinating their muscles to pass stool smoothly.

C. "This is normal behavior for infants unless the stool passed is hard and dry.": While hard and dry stools may indicate constipation, grunting and crying during bowel movements can still be normal behaviors in infants, regardless of the consistency of the stool.

D. "This indicates a blockage in the intestine and must be reported to the health care provider.": Grunting and crying during bowel movements are not necessarily indicative of a blockage in the intestine. These behaviors are common in infants and usually resolve as the infant's gastrointestinal system matures.

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Correct Answer is B

Explanation

A. Areola and papilla separate from the contour of the breast: This is a normal finding in breast development and indicates Tanner stage 4 or higher, which is typical for adolescent girls. It does not necessarily indicate a developmental delay.

B. Absence of first menstrual perioD. Menarche, the first menstrual period, typically occurs between the ages of 9 and 15 in girls. Absence of menarche by the age of 15 or within 3 years after the onset of breast development (thelarche) may indicate a developmental delay or underlying medical condition that should be evaluated by a healthcare provider.

C. Developed breast tissuE. Breast development, indicated by palpable breast tissue, is a normal part of female puberty and typically occurs before menarche. Developed breast tissue alone does not necessarily indicate a developmental delay.

D. Mature distribution and coarseness of pubic hair: Pubic hair development is also a part of female puberty and occurs before or around the time of menarche. While the distribution and coarseness of pubic hair can provide information about pubertal development, the absence of menarche is a more reliable indicator of a potential developmental delay.

A. Poisoning B. Drowning C. Unintentional injuries D. Diseases

Correct Answer is C

Explanation

A. Poisoning: While poisoning can be a significant concern among adolescents, it is not the

leading cause of death in this age group. Poisoning deaths may occur due to accidental ingestion of toxic substances or intentional overdose, but it is not as common as other causes of death

among adolescents.

B. Drowning: Drowning is a concern, especially during recreational activities such as swimming, but it is not the leading cause of death among adolescents. Proper water safety practices and supervision can help prevent drowning incidents.

C. Unintentional injuries: Unintentional injuries, including motor vehicle accidents, falls, and other accidents, are the leading cause of death among adolescents. Risk-taking behaviors, lack of experience, and peer influence contribute to the high rate of unintentional injuries in this age group.

D. Diseases: While diseases such as cancer, heart disease, and respiratory disorders can affect adolescents, they are not the leading cause of death in this age group. Unintentional injuries,

including those resulting from accidents and trauma, are more common causes of death among adolescents.

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A new mother expresses concern to the nurse that her baby is crying and grunting when passing stool. What is the nurse's best response to this observation?

Nursing Test Bank

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