A nurse is assessing an infant who has a ventricular septal defect. Which of the following should the nurse expect?
Weak femoral pulses
High blood pressure
Dysrhythmias
Loud, harsh murmur
The Correct Answer is D
A. Weak femoral pulses may be seen in other congenital heart defects but are not typically associated with VSD.
B. High blood pressure is not a typical finding in VSD, as the defect usually leads to increased blood flow to the lungs rather than systemic hypertension.
C. Dysrhythmias are not commonly associated with VSD unless there are other complicating factors.
D. A loud, harsh murmur is a classic finding in infants with a ventricular septal defect (VSD), due to the abnormal flow of blood through the hole in the septum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Polyuria is more commonly seen in hyperglycemia, not hypoglycemia, so it is unlikely to be present with a blood glucose level of 55 mg/dL.
B. Dry, flushed skin is typically a sign of hyperglycemia (e.g., in diabetic ketoacidosis), not hypoglycemia.
C. Deep, rapid respirations are a symptom of metabolic acidosis or severe hyperglycemia, not hypoglycemia.
D. Tachycardia is a common compensatory response to hypoglycemia, as the body tries to increase glucose delivery to tissues.
Correct Answer is C
Explanation
A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.
B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.
C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.
D. The nurse should address the issue, not refer to the provider for an explanation of their actions.
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