A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply.)
Clubbing of the fingers
Weak femoral pulses
Cool skin of lower extremities
Low blood pressure
Severe cyanosis
Correct Answer : B,C
Choice A reason: Clubbing of the fingers is not typically associated with coarctation of the aorta; it is more commonly seen in chronic hypoxia conditions.
Choice B reason: Weak femoral pulses are expected in coarctation of the aorta due to the narrowing of the aorta, which can reduce blood flow to the lower extremities.
Choice C reason: Cool skin of the lower extremities can be a result of decreased blood flow due to the narrowed aorta in coarctation.
Choice D reason: High blood pressure is more commonly associated with coarctation of the aorta, especially in the upper body, due to the narrowing of the aorta increasing resistance to blood flow⁷.
Choice E reason: Severe cyanosis can occur in coarctation of the aorta if there is a significant obstruction to blood flow, leading to poor oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While the Fowler's position can aid in breathing, it is not the first action to take if the oxygen saturation monitor is reading low.
Choice B reason: Ensuring the proper placement of the sensor probe is the first step, as incorrect placement can lead to inaccurate readings.
Choice C reason: Increasing the oxygen flow rate should only be considered after confirming the accuracy of the oxygen saturation reading.
Choice D reason: Encouraging deep breaths may be helpful, but it is not the first action to take. The priority is to ensure the oxygen saturation reading is accurate.
Correct Answer is C
Explanation
Choice A reason: The FACES scale is not typically used for infants as they cannot verbally express or select a face that correlates with their pain level.
Choice B reason: The Oucher scale requires a child to point to a face that shows how much pain they are feeling, which is not suitable for infants who cannot communicate their pain verbally.
Choice C reason: The FLACC scale is appropriate for infants as it assesses pain based on five categories of behavior: Facial expression, Leg movement, Activity, Cry, and Consolability.
Choice D reason: The Non-communicating children's pain checklist is designed for children with cognitive impairments and is not the best choice for assessing pain in infants.
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