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 C

Explanation

A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.

C. Place the child in an upright position.

Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.

D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.

A. Growth of that leg may be affected. B. Risk for infection at this location is increased C. Long bones contain marrow, which increases the risk for anemia D. Fracture repair will necessitate prolonged traction

Correct Answer is A

Explanation

A.Growth of that leg may be affected.

When a fracture occurs near the epiphyseal plate of a long bone, such as the femur, there is a risk of damage to the growth plate. The growth plate (epiphyseal plate) is responsible for longitudinal bone growth in children. If the growth plate is injured or damaged during the fracture, it can potentially lead to growth disturbances and affect the growth of that leg.

B. Risk for infection at this location is increased: While any fracture has a risk of infection, the proximity to the epiphyseal plate doesn't necessarily increase the risk of infection.

C. Long bones contain marrow, which increases the risk for anemia: The presence of bone marrow in long bones is unrelated to the potential effects on bone growth after a fracture near the epiphyseal plate.

D. Fracture repair will necessitate prolonged traction: The use of traction for fracture repair can vary depending on the type and location of the fracture. However, the primary concern with a fracture near the epiphyseal plate is its potential impact on bone growth.

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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

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take

Correct Answer is C

Explanation

A school-aged child with a fracture of the femur near the epiphyseal plate is admitted to the hospital. The parents ask if there will be any after effects when the bone heals. Which physiological characteristic of the femur should the nurse consider when preparing to respond?

Correct Answer is A

Explanation

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