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 C
Explanation
Choice A reason: Restricting calcium intake is not typically recommended for children with chronic renal failure as they may already be at risk for bone disease due to altered calcium metabolism.
Choice B reason: Eating three large meals per day and limiting snacks is not specific dietary advice for chronic renal failure; nutritional needs should be tailored to the individual.
Choice C reason: This is the correct choice. In chronic renal failure, the kidneys may not be able to remove excess potassium, leading to hyperkalemia, which can be dangerous.
Choice D reason: Increasing sodium intake is not generally recommended for chronic renal failure as it can contribute to hypertension and fluid retention.
Correct Answer is D
Explanation
Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.
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