The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities. Which assessment will the nurse perform next on this infant?

Pedal pulses.

Blood pressure of the four extremities.

Lower extremity reflexes.

Hemoglobin and hematocrit values.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing pedal pulses is important, but it does not provide complete information about the circulatory status of the infant.
Choice B reason: This is the correct choice. Discrepancies in pulse strength between the upper and lower extremities may indicate a cardiovascular problem such as coarctation of the aorta, which can be further evaluated by comparing blood pressures in all four extremities.
Choice C reason: Lower extremity reflexes are not directly related to the strength of pulses.
Choice D reason: Hemoglobin and hematocrit values are important but would not be the next step in assessing the significance of the difference in pulse strength.

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Correct Answer is C

Explanation

Choice A reason: A 7-year-old child may have some difficulty with separation but is typically able to understand the reason for hospitalization better than younger children.
Choice B reason: A 5-month-old infant may show signs of distress but does not have the same understanding of separation as an older child.
Choice C reason: This is the correct choice. A 4-year-old child is at a developmental stage where separation from family can cause significant distress and difficulty.
Choice D reason: A 15-month-old toddler may experience separation anxiety, but it is generally more intense in preschool-aged children.

A. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." B. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." C. "I was walking up the steps and slipped on the ice, falling while carrying my baby." D. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor."

Correct Answer is D

Explanation

Choice A reason: This choice might not arouse suspicion as it could be a plausible accident involving siblings.

Choice B reason: This choice also might not arouse suspicion as accidents can happen when children are playing and not being watched closely.

Choice C reason: This choice is less likely to arouse suspicion as slipping on ice is a common accident.

Choice D reason: This is the correct choice. The statement may arouse suspicion because it suggests negligence, as the caregiver left the baby unattended in a potentially dangerous situation.

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The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities. Which assessment will the nurse perform next on this infant?

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