A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?
Frequent nosebleeds.
Upper extremity hypotension.
Weak femoral pulses.
Increased intracranial pressure.
The Correct Answer is C
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
Choice A is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
Choice B is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
Choice D is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status. However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because abruptly stopping TPN can cause hypoglycemia, which is a low blood sugar level that can cause shakiness, diaphoresis, confusion, and seizures. Therefore, infusing dextrose 10% in water temporarily at the same rate as the TPN can prevent this adverse effect. Dextrose 10% in water is a hypertonic solution that contains 340 calories per liter and can maintain the client’s blood glucose level until the new TPN bag arrives.
Choice A is wrong because giving 500 mL of lactated Ringer’s solution would not provide enough calories or glucose to prevent hypoglycemia. Lactated Ringer’s solution is an isotonic solution that contains electrolytes but no calories or glucose.
Choice B is wrong because temporarily discontinuing the infusion would cause hypoglycemia, which can be life-threatening for the client.
Choice C is wrong because slowing the TPN infusion rate would also cause hypoglycemia, as the client would receive less calories and glucose than prescribed.
Correct Answer is B
Explanation
Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
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