The nurse is caring for a newborn diagnosed with patent ductus arteriosus. What assessment findings would be consistent with this diagnosis? (Select All that Apply.)
Circumoral cyanosis
Tachycardia
Elevated diastolic blood pressure
Bradycardia
Bounding peripheral pulses
Continuous murmur
Narrow pulse pressure
Correct Answer : B,E,F
A. Circumoral cyanosis. This can occur but is less specific for PDA and more related to general issues with oxygenation.
B. Tachycardia. PDA can lead to increased heart rate as the heart works harder to manage the increased blood flow.
C. Elevated diastolic blood pressure. PDA usually causes a decrease in diastolic pressure, not an increase.
D. Bradycardia. Bradycardia is not typically associated with PDA.
E. Bounding peripheral pulses. PDA allows more blood to flow into the systemic circulation, leading to stronger pulses.
F. Continuous murmur. PDA typically causes a continuous "machine-like" murmur because of the continuous flow of blood from the aorta to the pulmonary artery.
G. Narrow pulse pressure. PDA often causes a wide pulse pressure, not a narrow one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Correct Answer is ["A","B","C","E"]
Explanation
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
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