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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.

A. Elevate the child's residual limb for 48 hr. B. Apply a loose-fitting bandage onto the child's residual limb. C. Perform active and isotonic range-of-motion exercises. D. Clean the incision using half-strength hydrogen peroxide every 8 hr.

Correct Answer is C

Explanation

A. Elevate the child's residual limb for 48 hr. Elevation for prolonged periods can cause flexion contractures. Elevation is typically limited to the first 24 hours, if at all.
B. Apply a loose-fitting bandage onto the child's residual limb. A compression bandage, not loose-fitting, is used to shape the residual limb and reduce swelling.
C. Perform active and isotonic range-of-motion exercises. These exercises prevent contractures and maintain muscle strength.
D. Clean the incision using half-strength hydrogen peroxide every 8 hr. Hydrogen peroxide can damage healthy tissue and delay healing. Saline or antiseptic solutions are preferred.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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