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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Applying a warm soak to the knee: Heat application is generally not recommended during a vaso-occlusive crisis because it can worsen inflammation and pain.

B. Administering Acetaminophen.

Vaso-occlusive crises are a common complication of sickle cell disease, and they can lead to severe pain. Acetaminophen (Tylenol) is an appropriate choice for pain management in this situation. It is a non-steroidal anti-inflammatory drug (NSAID) that can help alleviate pain.Pain control is the priority in these situations.

C.Compression wraps can potentially exacerbate ischemia and increase the risk of complications.

D.Adequate hydration is essential during a crisis to prevent further sickling of red blood cells. Reducing fluids could exacerbate the condition

A. Inspect the mouth weekly for ulcerations B. Use a potent commercial mouthwash C. Clean the teeth manually with a soft toothbrush D. Visit a dental professional only during episodes of excessive bleeding or pain

Correct Answer is C

Explanation

A. Inspecting the mouth weekly for ulcerations is not sufficient. Children receiving chemotherapy should be encouraged to perform daily oral care, and any concerning symptoms should be reported promptly to the healthcare provider.

B. Using a potent commercial mouthwash is not recommended, as many commercial mouthwashes contain alcohol or other potentially irritating ingredients. A healthcare provider should recommend a suitable oral rinse if needed.

C. Clean the teeth manually with a soft toothbrush.

Children receiving chemotherapy are at risk of developing mouth sores (mucositis) and other oral complications. It is essential to maintain good oral hygiene to minimize the risk of infection and reduce discomfort. Using a soft toothbrush for gentle manual cleaning is recommended, as it helps to prevent injury to the sensitive oral tissues that can occur with a hard toothbrush.

D. Visiting a dental professional only during episodes of excessive bleeding or pain is not recommended. Regular dental check-ups are important for children receiving chemotherapy to monitor and address oral health issues. Waiting for symptoms of bleeding or pain may result in a delay in addressing potential problems.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent experiencing a vaso-occlusive crisis reports right knee pain. Which is the most appropriate intervention?

Correct Answer is B

Explanation

The nurse would include in a teaching plan about mouth care for a child receiving chemotherapy to:

Correct Answer is C

Explanation

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