The nurse is performing an assessment of the reproductive system of a 17-year-old girl. What would alert the nurse to a developmental delay in this girl?
Areola and papilla separate from the contour of the breast
Absence of first menstrual period
Developed breast tissue
Mature distribution and coarseness of pubic hair
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months
is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.
B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.
C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.
D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.
Correct Answer is A
Explanation
A. An infant's rate is 90 bpm.
An infant's normal heart rate typically ranges from 70 to 150
B. A toddler's rate is 150 bpm.
The normal heart rate for a toddler usually ranges from 70 to 130. Therefore a rate of 150 bpm would be considered tachycardia in a toddler.
C. A preschooler's rate is 130 bpm.
The normal heart rate for a preschooler typically ranges from 80 to 120 bpm, with an average rate around 100-110 bpm. A rate of 130 bpm would be considered tachycardia in a preschooler.
D. A school-age child's rate is 50 bpm.
The normal heart rate for a school-age child usually ranges from 75 to 118 bpm. A rate of 50 bpm would be considered bradycardia in a school-age child.
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