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

Answer and Explanation

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.

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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.

A. The nasal passages are narrower. B. The tongue is smaller. C. There are significantly fewer alveoli. D. The larynx is more funnel shaped. E. The trachea and chest wall are less compliant.

Correct Answer is ["A","C","D","E"]

Explanation

A. Narrower nasal passages can lead to increased airway resistance and difficulty in breathing, as infants are primarily nasal breathers.

B. A smaller tongue does not directly contribute to respiratory compromise; however, it can pose a risk for airway obstruction if the tongue falls back against the oropharynx.

C. Significantly fewer alveoli mean less surface area for gas exchange, which can impair oxygenation and carbon dioxide elimination.

D. A more funnel-shaped larynx can predispose infants to upper airway obstruction and increase the work of breathing.

E. Less compliant trachea and chest wall make it harder for the infant to expand the lungs, leading to increased work of breathing and potential respiratory distress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?

Correct Answer is D

Explanation

The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all that apply.

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions aredevelopmentally appropriate at which of the following ages?

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1⁄2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?

The nurse is providing teaching for the mother of an infant who receives all of his nutrition through a nasogastric feeding tube. The nurse is reviewing interventions to promote growth and development. Which response from the mother indicates a need for further teaching?

The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty?

A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Which of the following foods should the nurse recommend?