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?
Upper extremity hypotension
Weak femoral pulses
Frequent nosebleeds
Increased intracranial pressure
The Correct Answer is B
A. Coarctation of the aorta typically results in hypertension in the upper extremities due to increased pressure proximal to the coarctation.
B. Weak or absent femoral pulses are characteristic findings in coarctation of the aorta due to reduced blood flow to the lower extremities beyond the coarctation. This finding indicates peripheral vascular compromise in the lower limbs.
C. Frequent nosebleeds are not typically associated with coarctation of the aorta.
D. Coarctation of the aorta does not directly affect intracranial pressure.

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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. It's important not to repeat a dose of digoxin if vomited soon after administration due to the risk of toxicity. Instead, parents should contact their healthcare provider for guidance.
B. Mixing digoxin with a large volume of liquid can lead to inaccurate dosing if the child does not consume all the liquid.
C. Digoxin affects potassium levels in the heart muscle; thus, maintaining a normal dietary intake of potassium is important, not limiting it, as hypokalemia can increase the risk of digoxin toxicity.
D. Having water after taking digoxin helps ensure that the medication is swallowed completely and minimizes the risk of esophageal irritation. It aids in proper absorption of the drug.
Correct Answer is ["B","C","D","G","H"]
Explanation
A. Contact precautions are not indicated based on the assessment findings provided. Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
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