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.

Frequent nosebleeds.

Weak femoral pulses.

Increased intracranial pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.

Choice B rationale:

Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.

Choice D rationale:

Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.

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Correct Answer is B

Explanation

The correct answer is choice B: Axillary.

Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.

Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.

Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.

Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.

A. Review the need for the UAP to wear a face mask while in close contact with the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Assign the UAP to provide care for another client and assume full care of the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.

Choice B rationale:

A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.

Choice C rationale:

Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.

Choice D rationale:

Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.

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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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Correct Answer is A

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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?