The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

Hemiplegia.

Fever.

Vigorous feeding and satiation.

Hypotension and tachycardia.

Answer and Explanation

The Correct Answer is D

Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood ﬂow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate ﬂuid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.

Option A is not a typical finding associated with aortic stenosis.

Option B is not directly related to the infant's cardiac condition.

Option C is not a typical finding associated with heart failure.

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Correct Answer is C

Explanation

In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the ﬂow of food into the small intestine becomes thickened and narrowed.

Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.

A. Suggest placing the iron drops in the orange juice and then feeding the infant. B. Give the mother positive feedback about the way she administered the medication. C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops. D. Tell the mother to follow the iron drops with infant formula instead of orange juice.

Correct Answer is B

Explanation

The nurse should give the mother positive feedback about the way she administered the medication. Giving the infant orange juice after administering the iron drops is a good practice because vitamin C in the orange juice can enhance the absorption of iron. The other options (A, C, and D) are not appropriate actions for the nurse to take in this situation.

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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

Correct Answer is C

Explanation

The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

Correct Answer is B

Explanation

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