The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
“This is a vasomotor response caused by cooling or warming."
“This is normal her circulatory system will take a few days to adjust.”
"Let's watch her carefully to make sure she does not have a circulatory problem."
"Your daughter has acrocyanosis; this is causing her blue hands and feet.”
The Correct Answer is D
A. “This is a vasomotor response caused by cooling or warming": While vasomotor responses can cause changes in skin color due to temperature changes, acrocyanosis specifically refers to blue discoloration of the hands and feet due to reduced peripheral circulation, not necessarily due to temperature changes.
B. “This is normal her circulatory system will take a few days to adjust”: While it's true that newborns may have transient circulatory changes as their circulatory system adapts after birth, acrocyanosis specifically refers to a benign condition characterized by persistent blue discoloration of the extremities unrelated to circulatory adjustments.
C. "Let's watch her carefully to make sure she does not have a circulatory problem": While it's important to monitor infants for any signs of circulatory problems, acrocyanosis is typically a
benign and self-limiting condition that does not require intervention unless accompanied by other concerning symptoms.
D. "Your daughter has acrocyanosis; this is causing her blue hands and feet.”: This response provides an accurate explanation for the blue discoloration of the infant's hands and feet. Acrocyanosis is a common and benign condition in newborns characterized by blue discoloration of the extremities due to peripheral vasoconstriction, which gradually resolves over the first few days to weeks of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Myelination of the brain and spinal cord is a continuous process that begins during fetal development and continues through childhood and adolescence. While significant myelination
occurs during infancy and toddlerhood, it is not complete by 24 months. However, substantial progress in myelination does occur during the toddler years, contributing to the development of motor and cognitive skills.
B. Alveoli reach adult numbers by 3 years of age. This statement is incorrect. Alveoli continue to develop and increase in number after birth, reaching adult numbers around adolescence, not by 3 years of age.
C. Urine output in a toddler typically averages approximately 30 mL/hour. This statement is incorrect. Toddlers typically have higher urine output rates than adults due to their smaller
bladder capacity and higher metabolic rate. The average urine output for a toddler is around 1-2 mL/kg/hour, which varies depending on factors such as hydration status and activity level.
D. Toddlers typically have strong abdominal muscles by the age of 2. This statement is incorrect. While toddlers may develop some abdominal muscle strength through activities such as walking and climbing, their muscle tone and strength are still developing and may not be as strong as in older children or adults.
Correct Answer is D
Explanation
A. "It is best to just ignore this and to not respond to his questions.": Ignoring the child's questions about the death of his grandfather may lead to feelings of confusion or abandonment. It is important to address the child's concerns and provide appropriate support and guidance.
B. "He will eventually figure this out on his own.": While children may gradually come to understand the permanence of death as they mature, it is essential to provide support and explanations to help them cope with grief and loss.
C. "You have to keep repeating that his grandfather is never coming back.": Continually
repeating that the grandfather is never coming back may be distressing for the child and does not provide constructive support or help the child understand the concept of death.
D. "This is normal; children his age do not understand the permanence of death.": This response acknowledges the child's age-appropriate understanding of death and provides reassurance to the mother that her son's reaction is typical. It opens the door for the nurse to offer guidance on how to support the child through the grieving process and gradually help him comprehend the permanence of death.
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