A client asks the nurse, "What is the purpose of measuring the level of oxygen in my child's blood?" Which response by the nurse is accurate?
"It helps assess the electrical activity of the heart.”
"It evaluates the child's respiratory rate and effort.”
"It monitors oxygen saturation using pulse oximetry.”
"It measures the child's weight and developmental milestones.”
The Correct Answer is C
Choice A rationale:
Measuring the level of oxygen in a child's blood does not help assess the electrical activity of the heart.
Oxygen measurement and the assessment of heart electrical activity are two separate concepts.
Choice B rationale:
Measuring oxygen levels in the blood primarily evaluates the child's oxygen saturation, not the respiratory rate and effort.
While oxygen saturation is related to respiratory function, it doesn't directly assess the rate and effort of breathing.
Choice C rationale:
Measuring the level of oxygen in a child's blood monitors oxygen saturation using pulse oximetry.
Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood.
This is important because it provides information about the child's oxygen levels, which is crucial for assessing their respiratory and circulatory status.
Choice D rationale:
Measuring the level of oxygen in the blood does not measure the child's weight and developmental milestones.
This response is unrelated to the purpose of monitoring oxygen levels in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"This murmur is a sign of a heart defect called coarctation of the aorta (COA).”.
Choice A rationale:
"This murmur is a sign of a heart defect called coarctation of the aorta (COA).”.
A systolic ejection murmur heard at the left upper sternal border can be indicative of coarctation of the aorta (COA).
Coarctation of the aorta is a congenital heart defect characterized by a narrowing or constriction of the aorta, typically near the site of the ductus arteriosus.
This narrowing leads to increased pressure and turbulence in the left ventricle and aorta, resulting in the systolic ejection murmur.
Informing the client about the likely diagnosis is a good approach as it helps provide them with essential information about their condition.
Choice B rationale:
"This murmur is a sign of a heart defect called atrial septal defect (ASD).”.
An atrial septal defect (ASD) typically presents with a different type of murmur, not a systolic ejection murmur heard at the left upper sternal border.
ASD is characterized by a fixed, split second heart sound (S2) and a mid-systolic murmur at the upper left sternal border.
The description in the question does not align with the typical findings of an ASD.
Choice C rationale:
"This murmur is a sign of a heart defect called ventricular septal defect (VSD).”.
A ventricular septal defect (VSD) also presents with a different type of murmur, typically a harsh holosystolic murmur heard at the lower left sternal border.
The description of the murmur in the question, a systolic ejection murmur at the left upper sternal border, is not characteristic of a VSD.
Choice D rationale:
"This murmur is a sign of a heart defect called tetralogy of Fallot (TOF).”.
Tetralogy of Fallot (TOF) is characterized by a different set of heart defects, including a ventricular septal defect (VSD), overriding aorta, right ventricular outflow tract obstruction, and right ventricular hypertrophy.
The murmur described in the question is not specific to TOF and is more indicative of coarctation of the aorta (COA) due to its location and characteristics.
Correct Answer is A
Explanation
Choice A rationale:
The patient's statement, "My baby's skin and lips have turned bluish," is a classic symptom of cyanosis.
Cyanosis is a bluish or purple discoloration of the skin and mucous membranes, which occurs due to a lack of oxygen in the blood.
In this case, it's associated with a ventricular septal defect (VSD), which is a congenital heart defect that allows oxygen-poor blood from the right side of the heart to mix with oxygen-rich blood from the left side.
Choice B rationale:
The statement, "My baby has difficulty feeding and is not gaining weight properly," may be related to the VSD, but it is not a typical symptom of cyanosis.
This symptom can occur due to congestive heart failure in infants with VSD.
Choice C rationale:
"My baby gets tired quickly during physical activity" can also be associated with VSD and congestive heart failure, but it is not a direct symptom of cyanosis.
Choice D rationale:
"I can hear abnormal heart sounds during the check-up" is not a symptom but rather a sign of a ventricular septal defect.
Abnormal heart sounds, like a loud holosystolic murmur, may be heard on auscultation.
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