The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse expect?
Blood pressure variance across extremities.
Hypotension.
Tachycardia.
Pulse oximetry reading within defined limits.
Pulse oximetry reading within defined limits.
The Correct Answer is C
Choice A rationale
Blood pressure variance across extremities is not typically associated with unrepaired ventricular septal defect and heart failure in a toddler.
Choice B rationale
Hypotension is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.
Choice C rationale
Tachycardia, or a fast heart rate, is a common symptom in toddlers with unrepaired ventricular septal defect and heart failure. This is because the heart has to work harder to pump blood through the body.
Choice D rationale
While a pulse oximetry reading within defined limits is ideal, it is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Keeping plastic bags of ice in the freezer is not specifically indicative of successful management of hemophilia. While ice can be used to manage acute joint bleeds, it does not reflect the overall management of the condition.
Choice B rationale
Wearing extra pads when playing football could indicate an awareness of the risk of injury, but it does not necessarily reflect successful management of hemophilia. In fact, contact sports like football are generally not recommended for individuals with hemophilia due to the risk of bleeding.
Choice C rationale
Serving as a counselor at a camp for hemophiliacs could indicate successful management of hemophilia. It suggests that the individual has not only learned to manage their own condition, but is also able to provide guidance and support to others with the same condition.
Choice D rationale
Chewing food slowly to prevent injury to the gums is a precautionary measure, but it does not necessarily indicate successful management of hemophilia.
Correct Answer is B
Explanation
Choice A rationale
Preparing a vacuum is not the first action to take when the fetal head retracts against the perineum during the second stage of labor.
Choice B rationale
Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.
Choice C rationale
Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.
Choice D rationale
Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.
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