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 C
Explanation
A. Pancreatic enzymes should not be decreased for steatorrhea; they are required to help with digestion.
B. Fluid intake should not be restricted; hydration is important for children with cystic fibrosis.
C. Children with cystic fibrosis need a high-calorie, high-fat diet due to malabsorption of nutrients and increased energy needs.
D. Pancreatic enzymes should be administered with meals, not two hours after.
Correct Answer is A
Explanation
A. The child should sit upright with the head tilted forward to prevent blood from flowing down the throat, which could cause choking or aspiration. Applying pressure on the nostrils for 10 minutes is an effective method for stopping most nosebleeds.
B. While ice may help constrict blood vessels, it is not the primary intervention for a nosebleed. Holding pressure is more effective.
C. Tilting the head back can cause blood to flow into the throat and potentially lead to choking or vomiting.
D. Lying the child supine increases the risk of blood flowing into the throat and airway, making it unsafe.
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