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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.
Correct Answer is B
Explanation
Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.
Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.
Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.
Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.
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