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A nurse is assessing a 3•year.old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply).

Murmur

Bradycardia

Hypotension

Clubbing of the nail beds

Weak pulses

Answer and Explanation

Correct Answer : A,C,E

A. Murmur – Correct. Aortic stenosis typically causes a systolic murmur.

B. Bradycardia – Incorrect. Aortic stenosis usually leads to tachycardia due to decreased cardiac output.

C. Hypotension – Correct. Decreased blood flow from the heart can result in low blood pressure.

D. Clubbing of the nail beds – Incorrect. Clubbing is more commonly associated with chronic hypoxia, as seen in cyanotic heart defects.

E. Weak pulses – Correct. Reduced cardiac output can lead to weak or thready peripheral pulses.

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Correct Answer is C

Explanation

A. Is a congenital condition where the layers of the intestinal wall do not form properly. – Incorrect. This describes congenital gastrointestinal disorders like duodenal atresia, not intussusception.

B. Results from the twisting of the intestine, causing a blockage in the passage of food. – Incorrect. This describes volvulus, which is different from intussusception.

C. Occurs when one segment of the intestine slides into another, which can cut off blood supply. – Correct. Intussusception is a telescoping of the intestine, leading to obstruction and ischemia.

D. Is a consequence of weakened abdominal muscles, allowing a portion of the intestine to bulge. – Incorrect. This describes a hernia, not intussusception.

A. Monitoring for tachycardia B. Observing for diaphoresis during feeding C. Monitoring for polyuria D. Checking for hyperthermia E. Assessing for hepatomegaly F. Evaluating feeding difficulties

Correct Answer is ["A","B","E","F"]

Explanation

A. Monitoring for tachycardia – Correct. Tachycardia is an early sign of heart failure as the heart attempts to compensate for decreased cardiac output.

B. Observing for diaphoresis during feeding – Correct. Infants with heart failure often exhibit sweating while feeding due to increased effort and oxygen demand.

C. Monitoring for polyuria – Incorrect. Infants with heart failure are more likely to have oliguria due to poor perfusion, not excessive urination.

D. Checking for hyperthermia – Incorrect. Fever is not a primary sign of heart failure unless an infection is present.

E. Assessing for hepatomegaly – Correct. Hepatomegaly occurs due to systemic venous congestion, a hallmark of right-sided heart failure.

F. Evaluating feeding difficulties – Correct. Poor feeding and failure to thrive are common in infants with heart failure due to fatigue and respiratory distress.

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A nurse is assessing a 3•year.old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply).

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