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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
A. Lordosis: Lordosis is an excessive inward curvature of the spine, typically seen in the lower back. It is often referred to as "swayback."
B. Torticollis: Torticollis is a condition where the head is tilted to one side and may be rotated to the opposite side. It typically affects the neck muscles and is not related to lateral curvature of the spine.
C. Scoliosis.
Scoliosis is a lateral curvature of the spine. It is characterized by an abnormal sideways curvature of the spine, which can lead to an "S" or "C" shape of the spine. Scoliosis can occur during adolescence, and routine physical examinations may reveal this condition.
D. Kyphosis: Kyphosis is an excessive outward curvature of the spine, which can result in a rounded or hunched back, often seen in the upper back or thoracic spine.
In summary, the lateral curvature of the spine observed in this adolescent should be documented as scoliosis.
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