The nurse is examining an adolescent female and notes no pubic hair on the pubis area. The nurse would correctly choose which of the following actions? Standard Text: Select all that apply
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 normal.
5. Assess the client's dietary intake.
1,2,3
Rationale 1: Ask the client if she is menstruating. The presence or absence of menstrual history will aid in the determination of hormonal function.
Rationale 2: Examine the client for breast buds. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics.
Rationale 3: Report the findings to the healthcare provider. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up.
Rationale 4: Document the findings as normal. 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.
Rationale 5: Assess the client's dietary intake. Dietary intake information in the client who presents with physical immaturities in the event they also exhibit signs of nutritional deficiencies. There is no supportive information indicating that there are nutritional needs unmet.
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