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 B
Explanation
A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.
B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.
C. A blood pressure of 90/50 mm Hg is normal for a toddler.
D. A heart rate of 110/min is within the expected range for a 3-year-old.
Correct Answer is A
Explanation
Rationale:
A. Orthostatic hypotension (a significant drop in blood pressure when standing) could indicate a problem such as dehydration, hemorrhage, or shock and should be reported immediately.
B. Crying due to pain is common with burn injuries but does not indicate a life-threatening problem.
C. A pain increase after ambulation is expected in some cases but is not an emergency.
D. A mild temperature (99.5°F) postoperatively is not a cause for immediate concern.
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