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 A

Explanation

A. "You can give your child acetaminophen (Tylenol) every 4-6 hours as needed for pain."

Option A is the most appropriate response because it addresses pain management, which is a common symptom in cases of tonsillitis. Acetaminophen can be used to provide relief from pain and fever, which are often associated with viral tonsillitis. However, it's important for the parent to follow the dosing instructions on the medication label and consult with their healthcare provider if they have any concerns or if the child's condition worsens.

Option B ("You will need to schedule a follow-up appointment in 2 weeks") is also not the best initial response, as it doesn't address immediate care at home for the child's comfort and pain relief.

Option C ("You will need to give your child a prescribed antibiotic for 10 days") is not the correct approach, as antibiotics do not treat viral illnesses. Viral tonsillitis is usually caused by a viral infection, and antibiotics are not effective for viral infections.

Option D ("You can place warm towels around your child's neck for comfort") can provide some comfort but is not the primary treatment for viral tonsillitis. It may help alleviate discomfort, but pain relief with acetaminophen is typically more effective.

A. Alertness as such weight loss is not expected B. Reassurance as this is a normal weight loss C. Alarm as this is a drastic weight loss D. Concern as this may be an indicator of inadequate nutrition

Correct Answer is B

Explanation

A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.

B. Reassurance as this is a normal weight loss.

It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.

C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.

D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.

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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

A parent asks how to care for a child at home who has the diagnosis of viral tonsillitis. What is the nurse's best response?

Correct Answer is A

Explanation

The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

Correct Answer is B

Explanation

The nurse explains that the medication Prostaglandin E1 is being given to their child with transposition of the great vessels to:

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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