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. "Activity will increase the respiratory rate": While activity can indeed affect respiratory rate, counting for a full minute allows for a more accurate assessment of the newborn's baseline respiratory rate, regardless of activity level.
B. "The rate and rhythm of breath are irregular in newborns": This statement reflects an understanding of why a complete minute is necessary for counting the respiratory rate in newborns. Newborns often have irregular breathing patterns, so counting for a full minute helps ensure an accurate assessment of their respiratory rate.
C. "Newborns are abdominal breathers": While newborns primarily use their diaphragm to
breathe (abdominal breathing), this fact alone does not explain why the respiratory rate should be counted for a full minute.
D. "Newborns do not expand their lungs fully with each respiration": While newborns may not fully expand their lungs with each breath, this factor is not the primary reason for counting the respiratory rate for a full minute.
Correct Answer is D
Explanation
A. Set of building blocks: While building blocks can be engaging toys for children, they may not effectively address the emotional needs of a child experiencing distress or separation anxiety. Building blocks are more suitable for activities that promote creativity and fine motor skills.
B. Toy hammer and pounding boarD. Toys that involve physical activity, such as a toy hammer and pounding board, may not be appropriate for a child experiencing emotional distress. These toys may require energy and concentration that the child may not be able to focus on during a tantrum.
C. Picture book about hospitals: While a picture book about hospitals may help familiarize the child with the hospital environment, it may not provide immediate comfort during a tantrum. This type of resource may be more beneficial for preparing the child for medical procedures or explaining what to expect during hospitalization.
D. Stuffed animal: Providing a stuffed animal can offer comfort and reassurance to a child experiencing stress or separation anxiety. A soft and cuddly toy like a stuffed animal can serve as a transitional object, providing emotional support and security when the parent is not present. Children often form attachments to stuffed animals, which can help them cope with unfamiliar or challenging situations.
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