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 B
Explanation
A. Engaging the child in games with other children is important for social development, but it depends on the child's individual readiness and comfort level with social interactions. It's crucial to consider the child's temperament and developmental stage.
B. Encourage the child to feed himself finger foods.
At 18 months of age, children are typically developing their fine motor skills and independence. Encouraging self-feeding with finger foods is a developmentally appropriate activity. It promotes independence, fine motor skill development, and a positive feeding experience.
C. Allowing the child to walk independently on the nursing unit is appropriate if the child is developmentally ready and safe to do so. It promotes gross motor skill development and independence.
D. Holding and cuddling the child often is important for emotional and social development. However, the frequency and style of interaction should be individualized based on the child's preferences and needs. Some children may prefer more independence at this age.
Correct Answer is B
Explanation
A. Prevent ear infections: While individuals with cleft palates are at increased risk of ear infections, the primary immediate goal is not ear infection prevention.
B. Establish feeding and sucking.
Clefts of the soft palate can make it challenging for the baby to create a proper seal for sucking and feeding. Ensuring that the baby can feed effectively is a crucial initial goal. This may involve special nipples, bottles, or breastfeeding techniques to help the baby get proper nutrition.
While eventually repairing the cleft palate is an important part of the overall care plan, the immediate goal is to ensure that the baby can feed and gain weight properly.
C. Repair the cleft palate: Surgical repair of the cleft palate is typically done when the child is older. The immediate concern for a newborn is feeding.
D. Help the mother bond with the baby: This is an important aspect of care but not the primary goal for the baby's health and well-being. Bonding can occur while addressing the baby's feeding needs.
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