The nurse is performing an admission assessment on the neonate and finds femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be
Place the infant in reverse Trendelenburg position
Place the infant in the knee to chest position
Take the infant's blood pressure in all extremities
Notify the Physician
The Correct Answer is C
Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.
Option C. Take the infant's blood pressure in all extremities.
In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.
Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Your husband is correct. Constant attention makes an infant irritable and spoiled." This statement is not accurate. Infants need responsive caregiving and interaction with their caregivers for healthy emotional development. Providing attention to meet the baby's needs is not synonymous with spoiling.
B. "Your husband is concerned for you as giving so much attention to an infant significantly depletes your energy." While it's true that caring for a baby can be physically demanding and exhausting for parents, this response doesn't address the husband's concern and doesn't provide guidance on infant care.
C. "Your husband is not correct. Interaction helps an infant establish trust."
Option C provides the most appropriate response because it supports the importance of interaction and bonding with the infant, especially during the early stages of development. Establishing trust and attachment with the baby is crucial for their emotional and psychological well-being. Responsive caregiving and interaction with the infant is not associated with spoiling but rather with healthy child development.
D. "Your husband knows what he is talking about. A lot of attention causes a child to become self-centered." This response is not supported by current child development research. Proper attention and interaction with an infant promote healthy attachment and emotional development rather than causing self-centeredness.
Correct Answer is C
Explanation
Option A ("Considering the presence of diabetes but treating the child the same as the other children") is not the best approach because children with diabetes require individualized care and monitoring.
Option B ("Limiting fluid intake during school hours") is not an appropriate intervention and could potentially worsen the child's diabetes management. Hydration is important, and fluid intake should be based on the child's needs.
Option C. Asking the child each day what was eaten for breakfast.
Children with type 1 diabetes, especially those prone to morning hypoglycemic episodes, can benefit from close monitoring of their dietary choices and blood glucose levels. Asking the child what was eaten for breakfast allows the school nurse to assess whether the child had an appropriate meal and whether the insulin dosage may need adjustment. It helps identify potential factors contributing to hypoglycemia and provides valuable information for the child's diabetes management.
Option D ("Checking several times a day for injuries because of participation in the physical education program") is a good practice but does not specifically address the management of morning hypoglycemia. It is essential to monitor the child's safety during physical activities, but addressing breakfast choices and insulin management is more directly related to managing morning hypoglycemia.
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