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The nurse reviews the history and physical and assessment.

Select the 3 findings that require immediate follow up by the nurse.

Dry skin

Testicular rugae

Decreased tone

Mild tachypnea

Thin lanugo present

Nasal flaring

Answer and Explanation

Correct Answer : C,D,F

Brief introduction:

Preterm neonates born at 32 weeks exhibit physiological immaturity of the respiratory and neurological systems. Common clinical complications include surfactant deficiency leading to atelectasis and poor muscle tone reflecting incomplete neurological development and potential hypoxia.

Rationale:

A. Dry skin is an expected finding in some neonates and does not represent an acute physiological threat compared to respiratory or neurological concerns. Preterm skin is often translucent and thin rather than dry, but this does not require immediate follow up. It is managed with routine emollients and humidity.

B. Testicular rugae are actually expected to be absent or minimal in an infant born at 32 weeks gestation. The presence of undescended testes and smooth scrotal sac are normal developmental findings for this gestational age. This does not indicate an acute pathology requiring urgent medical or nursing intervention.

C. Decreased tone in a preterm infant is a significant finding that may indicate neurological distress, sepsis, or exhaustion from increased work of breathing. Normal infants should demonstrate flexed extremities and active movement. A limp posture requires immediate intervention to rule out metabolic instability or intracranial hemorrhage.

D. Mild tachypnea, defined as a respiratory rate > 60 breaths/minute, indicates the neonate is struggling to maintain gas exchange due to immature lung tissue. In preterm infants, this often precedes respiratory failure and requires constant monitoring of oxygen saturation levels. The nurse must assess if supplemental oxygen is sufficient to prevent further decompensation.

E. Thin lanugo is a normal physical characteristic of a neonate born at 32 weeks. Fine downy hair typically covers the back and shoulders of preterm infants and disappears as they approach full term status. Its presence confirms gestational age rather than suggesting an acute medical emergency or clinical complication.

F. Nasal flaring is a classic sign of respiratory distress as the infant attempts to decrease airway resistance and increase tidal volume. It is often accompanied by retractions or grunting in premature babies with low lung compliance. This physical finding suggests that the current 24% oxygen hood delivery may be inadequate for the infant.

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Correct Answer is A

Explanation

In emergency pediatric resuscitation, the rapid and accurate assessment of perfusion is critical. Infants (children under one year of age) possess unique anatomical characteristics, such as a short, thick neck and smaller peripheral vessels, that make traditional adult pulse points unreliable. According to the American Heart Association (AHA) and International Liaison Committee on Resuscitation (ILCOR) guidelines, the pulse check should take no more than 10 seconds to minimize delays in starting chest compressions if the infant is pulseless or has a heart rate below 60 beats per minute with signs of poor perfusion.

Rationale:

A. Over the brachial artery: The brachial artery is located on the inner aspect of the upper arm, between the infant's elbow and shoulder. Because infants have shorter necks with more subcutaneous fat, the brachial artery is more accessible and easier to palpate accurately than the carotid artery.

B. Over the left 4th intercostal space mid-clavicular line: An apical pulse is used for routine clinical assessments, but is not the recommended site for a rapid pulse check during an emergency resuscitation sequence.

C. Over the carotid artery: This is the standard pulse check site for adults and children (past the age of one). In infants, the carotid artery is difficult to locate due to the presence of neck folds and a shorter neck structure, leading to potential delays in starting CPR.

D. Over the radial artery: The radial pulse is a peripheral pulse that may be weak or absent in an infant experiencing respiratory distress or shock. It is never used as a diagnostic site to determine the need for CPR in an unresponsive victim.

A. "I'm going to eat the cookies last with my coffee." B. "I need an additional serving of butter for my roll." C. "The meat patty with gravy needs more salt." D. "I would like skim milk instead of whole milk,

Correct Answer is D

Explanation

Brief introduction:

Peripheral artery disease is a chronic circulatory condition where atherosclerotic plaques narrow the peripheral arteries, primarily in the lower extremities. This narrowing significantly reduces tissue perfusion, leading to intermittent claudication and an increased risk for critical limb ischemia. Nutritional therapy focuses on managing hyperlipidemia and hypertension to stabilize arterial endothelium and prevent the progression of systemic vascular narrowing and potential cardiovascular events.

Rationale:

A. Consuming refined sugars found in cookies contributes to a high glycemic load, which promotes systemic inflammation and metabolic dysfunction. While not as directly linked to plaque as saturated fats, excessive sugar intake supports oxidative stress within the arterial walls. High sugar intake does not promote the structural integrity required for healthy blood flow.

B. Butter is a significant source of saturated fat and cholesterol, which accelerate the formation of intimal plaques within the arterial system. Adding extra fat to a meal is contraindicated for clients with peripheral artery disease, as it worsens atherosclerotic progression. Dietary management must prioritize the reduction of animal fats to maintain vascular patency.

C. Excessive sodium intake from salt and gravy leads to water retention and increased peripheral resistance, exacerbating hypertension. Elevated blood pressure places mechanical stress on the arterial walls, further damaging the endothelial lining and worsening ischemia. Clients with vascular disease must adhere to a low-sodium diet to protect distal circulation.

D. Choosing skim milk over whole milk demonstrates a commitment to reducing saturated fat intake, which is essential for managing blood cholesterol levels. Lowering low-density lipoprotein (LDL) levels reduces the rate of plaque accumulation in the femoral and popliteal arteries. This dietary choice directly supports the maintenance of arterial lumen diameter and improved circulation.

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The nurse reviews the history and physical and assessment. Select the 3 findings that require immediate follow up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Correct Answer is A

Explanation

A client with peripheral artery disease receives a meal tray from the dietary department. Which statement indicates to the nurse that the client is following a meal plan to support healthy blood flow?

Correct Answer is D

Explanation

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The nurse reviews the history and physical and assessment.

Select the 3 findings that require immediate follow up by the nurse.