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 B
Explanation
A. "Can you stand very still while I feel how warm you are?": Toddlers may have difficulty understanding abstract requests or instructions. Asking a toddler to stand still to feel warmth may not effectively communicate the purpose of the assessment and may lead to confusion or
resistance.
B. "I am going to listen to your heart.": This statement provides clear, simple language that the toddler can understand. It prepares the child for the assessment and helps establish trust and cooperation.
C. "Can I listen to your lungs?": While this statement is appropriate for assessing respiratory sounds, it may not be as clear or specific as stating the intention to listen to the heart. Toddlers may not understand the term "lungs" as readily as "heart."
D. "I am going to take your blood pressure now.": This statement may cause anxiety or fear in the toddler, especially if they are unfamiliar with the procedure. It is important to prepare the child for each aspect of the assessment in a developmentally appropriate manner.
Correct Answer is B
Explanation
A. "You should leave the room while the tantrum is happening.": Leaving the room during a
toddler's tantrum may not be the most effective strategy, as it may reinforce the behavior or make the child feel abandoned. It is generally recommended to stay nearby and provide support and guidance during tantrums.
B. "Temper tantrums are the toddler's attempt to gain control of a situation.": Temper tantrums are often a normal part of toddler development and can occur when toddlers feel frustrated, overwhelmed, or unable to express their needs effectively. Understanding that tantrums are a way for toddlers to assert some control over their environment can help parents respond appropriately.
C. "Temper tantrums are a type of learning disability.": Temper tantrums are not indicative of a learning disability. While they can be challenging for parents to manage, they are typically considered a normal phase of development and are not associated with cognitive impairments.
D. "You should get a psychological consult for the temper tantrums.": Seeking psychological consultation for temper tantrums may be unnecessary unless there are other concerning behaviors or developmental delays present. Tantrums are typically addressed through behavior
management techniques and parent education rather than psychological intervention.
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