A nurse is assessing a young child and suspects coarctation of the aorta based on which finding?
Hypotension
Unequal upper and lower extremity pulses
Excessive crying
Diastolic murmur
The Correct Answer is B
A. Hypotension is not typically associated with coarctation of the aorta; it more often leads to hypertension in the upper body.
B. Unequal pulses in the upper and lower extremities are a classic sign of coarctation of the aorta, as the obstruction typically affects blood flow to the lower body.
C. Excessive crying is not a specific indicator of coarctation of the aorta and can occur due to various reasons.
D. A diastolic murmur is not a primary indicator of coarctation of the aorta; it is more associated with other cardiac conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A bulging fontanel indicates increased intracranial pressure or fluid overload, not dehydration. With dehydration, you expect a sunken fontanel.
B. Bradypnea (slow breathing) is not typically associated with dehydration and may indicate other issues.
C. A capillary refill time of 3 seconds suggests delayed perfusion, but it is not as indicative of severe dehydration as other signs.
D. Severity of dehydration is classified by percentage of body weight lost:Severe: ≥10% loss, moderate: 6–9% loss, mild: 3–5% loss. A 13% loss = severe dehydration, which matches the scenario.
Correct Answer is D
Explanation
A. Switching formula is not the first intervention, as projectile vomiting in an infant can indicate a more serious condition such as pyloric stenosis, which requires medical evaluation.
B. Oral rehydration solution may be needed if the infant is dehydrated, but the cause of vomiting must be assessed first.
C. While burping can reduce gas and discomfort, it is unlikely to resolve projectile vomiting, which may be due to a more serious underlying condition.
D. Bringing the baby to the clinic is the most appropriate action, as projectile vomiting can be a sign of pyloric stenosis or another serious condition that requires prompt medical attention.
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