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 D
Explanation
Option A, "Fatigue," is a symptom of anemia but is not a long-term complication associated with Thalassemia major.
Option B, "Deferoxamine usage," is a treatment to manage iron overload and not a complication associated with Thalassemia major.
Option C, "Immunosuppressive therapy," is not typically used to manage Thalassemia major and is not a long-term complication but rather a potential treatment for certain cases of thalassemia.
Option D. Hemochromatosis/Hemosiderosis
Thalassemia major is a genetic disorder that results in the body's inability to produce enough hemoglobin, leading to severe anemia.
To manage this condition, frequent blood transfusions are required, which can lead to iron overload in the body. Excess iron gets deposited in various organs and tissues, causing damage.
Hemochromatosis or hemosiderosis is a condition characterized by the accumulation of iron in organs like the liver, heart, and endocrine glands, which can result from repeated blood transfusions.
The complications associated with iron overload include liver damage, heart problems, diabetes, and more. Treatment with iron chelating agents like deferoxamine is often necessary to remove excess iron from the body.
Correct Answer is ["A","C","E"]
Explanation
A. Fatigue: Children with ALL often experience fatigue and weakness due to decreased red blood cell and platelet production as a result of bone marrow involvement by leukemia cells.
C. Pallor: Pallor, or paleness, is a common finding in children with ALL because of anemia (reduced red blood cell count).
E. Multiple bruises: Children with ALL may have an increased tendency to bruise and bleed due to low platelet counts, making them susceptible to easy bruising and petechiae.
The other options, B (Generalized edema) and D (Jaundice), are not typical clinical findings associated with ALL. Generalized edema is not a common symptom, and jaundice (yellowing of the skin and eyes) is more commonly associated with liver conditions, not leukemia.
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