The nurse is examining an adolescent female and notes no pubic hair on the pubis area. Based on this data, which action by the nurse is appropriate?
1. Ask the client if she is menstruating.
2. Examine the client for breast buds.
3. Report the findings to the healthcare provider.
4. Document the findings as abnormal.
Correct Answer: 4
According to Tanner's Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up. Potentially related factors will need to be investigated. Subjective data related to menstruation are relevant to the situation. The presence or absence of menstrual history will aid in the determination of hormonal function. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics.
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