A nurse in a provider's office is collecting baseline preoperative data from a 5-month-old infant who has coarctation of the aorta. Which of the following locations should the nurse palpate to check for the presence of the infant's femoral pulse?
A
B
C
The Correct Answer is B
A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.
B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.
C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Prepare the client for an emergency cesarean birth: Emergency cesarean delivery is indicated in cases of fetal distress or placenta previa with severe bleeding at term. In a hydatidiform mole, there is no viable fetus, and the priority is evacuation of the molar tissue rather than delivery by cesarean section.
- Prepare the client for suction curettage: Suction curettage is the treatment of choice for a hydatidiform mole. It allows for the complete evacuation of abnormal trophoblastic tissue, preventing complications such as severe hemorrhage and progression to malignant gestational trophoblastic disease.
- Anticipate a prescription for methotrexate: Methotrexate is primarily used to treat ectopic pregnancies or persistent gestational trophoblastic disease after a molar pregnancy, not for initial management. Immediate evacuation of the mole by suction curettage is the first-line intervention for this client.
- Remind the client that weekly blood tests are needed to measure pregnancy hormone: Following a molar pregnancy, weekly beta-hCG tests are critical to monitor for residual trophoblastic tissue or the development of choriocarcinoma. A declining beta-hCG confirms the resolution of disease, while a plateau or rise indicates persistent disease.
- Administer terbutaline: Terbutaline is a tocolytic medication used to relax the uterus in cases of preterm labor. In the case of a hydatidiform mole, uterine evacuation is necessary rather than uterine relaxation, making terbutaline inappropriate for this situation.
- Vaginal bleeding: Clients with a hydatidiform mole are at risk for significant vaginal bleeding due to the abnormal growth of trophoblastic tissue. Monitoring the amount and type of vaginal bleeding helps detect hemorrhage or retained molar tissue requiring urgent intervention.
- Blood pressure: Elevated blood pressure is a potential complication of hydatidiform mole, similar to preeclampsia, and can occur even in the first or second trimester. Regular monitoring of blood pressure is essential to detect worsening hypertensive symptoms early.
- Uterus for hypertonicity: Hypertonicity of the uterus is typically monitored in cases of labor or uterine rupture concerns. In a hydatidiform mole, the uterus is distended by abnormal tissue but hypertonicity is not a primary concern needing monitoring in this condition.
- Unilateral pelvic pain: Unilateral pelvic pain is more characteristic of ectopic pregnancy rather than a molar pregnancy. In hydatidiform mole, generalized uterine enlargement and discomfort are more typical, so unilateral pelvic pain is not a focus for this client.
- Cervical dilation per provider: Cervical dilation is not the main indicator of progress or concern with a molar pregnancy. The focus is on removing molar tissue and monitoring beta-hCG levels, not on the progress of cervical changes like in labor.
Correct Answer is D
Explanation
A. Attach a blood pressure cuff to the client's upper arm: A blood pressure cuff is not involved in obtaining a 12-lead ECG. Although blood pressure may be assessed separately, it is not part of the ECG procedure itself and would not aid in capturing accurate cardiac electrical activity.
B. Assist the client to the orthopneic position: The orthopneic position, which involves leaning forward, is used to ease breathing difficulties, not for ECG recording. For an ECG, the client should be lying flat or in a semi-reclined supine position to ensure consistent and accurate electrode placement.
C. Tell the client to expect a mild stinging sensation during the test: A 12-lead ECG is a painless, non-invasive procedure. Electrodes are applied to the skin's surface to measure electrical activity; there should be no pain or stinging involved unless the skin is abraded during preparation.
D. Instruct the client to remain as still as possible during the recording: Movement can cause artifacts on the ECG tracing, making it difficult to interpret accurately. Instructing the client to stay still helps ensure a clean recording and minimizes interference from muscle tremors or motion.
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