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A nurse on a pediatric unit is caring for a 5-week-old infant.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

2000:

Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist.

2200:

Infant asleep in crib. Heart rate regular, no murmur on auscultation.

Vital Signs

2000:

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Temperature 37° C (98.6° F)

Oxygen saturation 97% on room air, right wrist

Trunk, arms, and hands warm to palpation

Edema noted to hands, feet, and periorbital area

Weak bilateral femoral pulses

Lower extremities cool to palpation

Mucous membranes pink and moist

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Answer and Explanation

The Correct Answer is ["B","C","D","F"]

Findings that require follow-up:

Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Maintain aseptic technique during the child's dressing changes." Aseptic technique reduces the risk of infection, which is critical for children with burns as their immune response may be compromised.
B. "Provide low-calorie snacks for the child several times each day." Children with burns require a high-calorie, high-protein diet to promote healing and compensate for increased metabolic demands.
C. "Apply continuous passive motion devices to the child's lower extremities during periods of rest." Passive motion devices are not typically indicated for burn injuries unless there is joint involvement requiring physical therapy for mobility restoration.
D. "Administer pain medication to the child 30 min following physical therapy." Pain medication should be administered before physical therapy to improve tolerance and participation.

A. Urine output of 50 mL in 2 hr B. Lethargy C. Respiratory rate 24/min D. Absent Babinski reflex

Correct Answer is B

Explanation

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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