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 A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.
Choice B rationale
Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.
Choice C rationale
While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.
Choice D rationale
Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.
Correct Answer is C
Explanation
Choice A rationale
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. While it can have serious implications for the mother and baby, it is not directly linked to the development of spina bifida occulta in the newborn.
Choice B rationale
Tobacco use during pregnancy can lead to several complications, including low birth weight, preterm birth, and certain birth defects. However, it is not identified as a significant risk factor for spina bifida occulta.
Choice C rationale
Folic acid deficiency during pregnancy is a well-known risk factor for neural tube defects, including spina bifida. Spina bifida occulta is a mild form of spina bifida caused by a gap forming between the vertebrae in the spinal cord during fetal development. Adequate intake of folic acid, especially during the early stages of pregnancy, can help prevent such defects.
Choice D rationale
Short interval pregnancy refers to pregnancies that are closely spaced. While they can lead to complications such as preterm birth and low birth weight, they are not directly associated with an increased risk of spina bifida occulta.
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