A nurse caring for a child with a congenital heart defect is performing a physical examination.
Which statement reflects an appropriate action during the assessment?
"I will check the child's oxygen saturation using a pulse oximeter.”
"I'll ensure the child receives all their vaccinations today.”
"I'll assess the child's neurological development.”
"I will monitor the child's growth based on height alone.”
The Correct Answer is A
Choice A rationale:
Checking the child's oxygen saturation using a pulse oximeter is an appropriate action during the assessment of a child with a congenital heart defect.
Oxygen saturation monitoring helps assess the child's oxygen levels, which is crucial in determining the adequacy of oxygen supply to the body.
Children with congenital heart defects are at risk of reduced oxygen levels, and monitoring oxygen saturation is a vital part of their care.
Choice B rationale:
Ensuring the child receives all their vaccinations is important for the child's overall health but is not directly related to the assessment of a congenital heart defect.
Vaccinations are typically administered as part of routine healthcare, but they do not address the specific concerns related to a congenital heart defect assessment.
Choice C rationale:
Assessing the child's neurological development is important but is not the primary focus of the assessment for a congenital heart defect.
While neurological assessment is important for overall child development, it does not directly relate to the cardiac assessment.
Choice D rationale:
Monitoring the child's growth based on height alone is not a comprehensive assessment for a child with a congenital heart defect.
Monitoring growth should include various parameters, such as weight, head circumference, and developmental milestones.
Relying solely on height may not provide a complete picture of the child's overall development.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale:
"I have been feeling very tired lately and I am unable to eat properly.”.
This choice does not address the specific symptoms associated with a Ventricular septal defect (VSD) and is not the best response to the nurse's findings.
While tiredness and poor feeding may be related to heart failure, it does not directly reflect the symptoms associated with VSD, such as breathlessness and sweating with exertion.
Choice B rationale:
"I have been experiencing shortness of breath and rapid weight gain.”.
This is The correct answer.
The symptoms of shortness of breath and rapid weight gain align with the typical presentation of a VSD.
VSD can lead to heart failure, which results in fluid retention, manifesting as rapid weight gain, and shortness of breath due to congestion in the lungs.
Choice C rationale:
"I have been feeling dizzy and fainting frequently.”.
This choice describes symptoms that can be related to various health issues, but it doesn't directly correlate with the characteristic signs of VSD.
The primary symptoms in VSD are related to heart failure, and while dizziness and fainting can occur with severe heart issues, they are not the primary indicators in this case.
Choice D rationale:
"I have been having severe chest pain and palpitations.”.
This response does not align with the typical symptoms of VSD.
While palpitations can be associated with heart issues, chest pain is not a common symptom of VSD.
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