The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?
Pulmonary atresia
Tetralogy of Fallot
Ventricular septal defect
Coarctation of the aorta
The Correct Answer is D
A. Pulmonary atresia involves a blockage of blood flow to the lungs, but it does not specifically lead to differences in blood pressure in the extremities.
B. Tetralogy of Fallot involves four defects, but it does not directly correlate with differences in blood pressure between the extremities.
C. A ventricular septal defect can cause heart failure, but it typically doesn’t affect blood pressure in the extremities.
D. Coarctation of the aorta is a congenital defect where the aorta is narrowed, leading to higher blood pressure in the upper extremities and lower blood pressure in the lower extremities. This is why blood pressures are measured in all four extremities to identify this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A WBC of 6,000/mm³ is within the normal range (4,500-11,000/mm³), and a postoperative infection is more likely to result in an elevated WBC count.
B. Purulent nasogastric drainage is more suggestive of a gastrointestinal issue unrelated to a perforated appendix and is not a common finding post-surgery.
C. Passage of dark red stool with mucus could suggest gastrointestinal bleeding or infection, but it is not typical postoperatively after a perforated appendix.
D. After surgery for a perforated appendix, peristalsis may be absent initially due to the effects of anesthesia, bowel manipulation, or inflammation from the infection. This is a normal postoperative finding.
Correct Answer is A
Explanation
A. The child should sit upright with the head tilted forward to prevent blood from flowing down the throat, which could cause choking or aspiration. Applying pressure on the nostrils for 10 minutes is an effective method for stopping most nosebleeds.
B. While ice may help constrict blood vessels, it is not the primary intervention for a nosebleed. Holding pressure is more effective.
C. Tilting the head back can cause blood to flow into the throat and potentially lead to choking or vomiting.
D. Lying the child supine increases the risk of blood flowing into the throat and airway, making it unsafe.
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