A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?
Weak pulses
Chronic hypoxemia
Systolic murmur
Cyanosis with crying
The Correct Answer is C
Rationale:
A. Weak pulses are not typically associated with a large patent ductus arteriosus. Instead, bounding pulses may be observed due to increased blood flow to the lower extremities.
B. Chronic hypoxemia may occur in some cases of patent ductus arteriosus, but it is not a specific manifestation typically associated with this condition.
C. Systolic murmur is a common finding in newborns with a large patent ductus arteriosus. This murmur is often continuous with the second heart sound and may be heard best at the left upper sternal border.
D. Cyanosis with crying is not typically associated with patent ductus arteriosus. Cyanosis may occur in other cardiac defects but is not a specific finding for patent ductus arteriosus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Smiles when a parent appears: This is a social and emotional developmental milestone typically achieved by an 8-month-old infant and is not indicative of cerebral palsy.
B. Sits with pillow props: Difficulty sitting without support or requiring props to maintain a sitting position can be a manifestation of cerebral palsy, reflecting motor delays and impaired muscle control.
C. Tracks an object with eyes: Tracking objects with eyes is a visual developmental milestone and does not directly relate to cerebral palsy.
D. Uses a pincer grasp to pick up a toy: The pincer grasp typically develops around 9 to 12 months of age and is not directly related to cerebral palsy.
Correct Answer is []
Explanation
Potential condition
Correct Answer: B. Meningocele
Rationale: Based on the provided physical examination details, the newborn is most likely experiencing a meningocele, which is indicated by the presence of a sac in the lumbar area. This condition is a type of neural tube defect where a sac of fluid comes through an opening in the baby's back. However, the absence of other neurological symptoms and the intactreflexes suggest that the condition has not severely affected the newborn's neurological functions.
Actions to Take (2)
Correct Answers: C, E
The two actions the nurse should take to address this condition include: applying a non-adhering sterile saline moist compress to the sac to prevent it from drying and to protect it from trauma, and educating the guardians about the condition, its implications, and the potential need for surgical intervention to repair the defect.
Parameters to monitor
Correct Answer: A, C
Rationale: The two parameters the nurse should monitor to assess the newborn's progress are the head circumference and serial head ultrasounds. Monitoring head circumference is crucial as an increase may indicate hydrocephalus, which can be associated with meningocele. Serial head ultrasounds are necessary to assess for any changes in the brain structure or development of hydrocephalus. These measures will help ensure that any complications are identified and managed promptly.
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