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

Increased intracranial pressure

Upper extremity hypotension

Weak femoral pulses

Answer and Explanation

The Correct Answer is D

A. Frequent nosebleeds: While hypertension can occur in coarctation of the aorta, frequent nosebleeds are not a typical finding associated with this condition.

B. Increased intracranial pressure: This is not a direct finding of coarctation of the aorta. Increased intracranial pressure may be related to other conditions, but it is not specifically expected in this context.

C. Upper extremity hypotension: In coarctation of the aorta, the upper extremities usually experience higher blood pressure due to the narrowing of the aorta distal to the branches supplying the arms. Therefore, hypotension in the upper extremities is not expected.

D. Weak femoral pulses: This is an expected finding in coarctation of the aorta, as the narrowing of the aorta can lead to decreased blood flow to the lower body, resulting in weak or diminished femoral pulses compared to the upper extremities.

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Correct Answer is A

Explanation

A) The anterior fontanel is open: This is an expected finding in an 8-month-old infant. The anterior fontanel typically remains open until around 12 to 18 months of age, allowing for brain growth.

B) Both fontanels show molding: Molding is usually a temporary shape change of the skull that occurs during birth, particularly in relation to the birth canal. By 8 months, the fontanels should not show molding.

C) Both fontanels are the same size: The anterior fontanel is generally larger than the posterior fontanel. The posterior fontanel typically closes by 2 to 3 months of age and is much smaller.

D) The posterior fontanel is open: This finding is not expected, as the posterior fontanel should have closed by 2 to 3 months of age. An open posterior fontanel at 8 months could indicate a developmental concern.

A. Shave hairy areas of skin prior to application. B. Wear gloves to apply the patch to the client's skin. C. Apply the patch within 1 hr of removing it from the protective pouch. D. Remove the previous patch and place it in a tissue.

Correct Answer is B

Explanation

A) Shaving hairy areas of skin prior to application: While it's important to have a clean area for patch application, shaving can cause irritation and micro-abrasions, potentially leading to increased absorption or skin reactions. Instead, the nurse should clean the area and trim hair if necessary without shaving, to ensure the skin is intact.

B) Wear gloves to apply the patch to the client's skin: Using gloves is essential for infection control and to prevent the nurse from absorbing nicotine through their skin during application. It minimizes the risk of cross-contamination and ensures that the patch is applied safely and effectively.

C) Apply the patch within 1 hr of removing it from the protective pouch: The nicotine patch should be applied immediately after removal from the protective pouch to ensure that it maintains its efficacy. However, there is no strict guideline that requires it to be applied within one hour, making this less critical compared to the importance of proper technique during application.

D) Remove the previous patch and place it in a tissue: Proper disposal of the old patch is important to prevent accidental nicotine exposure. However, the patch should be discarded in a way that minimizes risk, such as folding it upon itself and placing it in a designated waste container rather than just a tissue, which may not secure it adequately.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?

Correct Answer is A

Explanation

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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