The nurse reviews the orders and identifies this infant most likely has which of the following?

A heart defect with increased pulmonary blood flow

A heart defect with a left to right shunt

A heart defect with a right to left shunt

An obstructive heart defect

None

Answer and Explanation

The Correct Answer is C

Rationale:

A. A heart defect with increased pulmonary blood flow: Increased pulmonary blood flow defects (such as VSD or PDA) typically present with higher oxygen saturations and signs of pulmonary congestion. Infants with these defects usually do not require oxygen restriction, as supplemental oxygen generally improves saturations without causing hemodynamic instability.

B. A heart defect with a left to right shunt: Left-to-right shunts send oxygenated blood back to the lungs, increasing pulmonary flow and often raising oxygen saturation levels. These infants usually show tachypnea and feeding difficulty but maintain higher O₂ levels than 82%.

C. A heart defect with a right to left shunt: Cyanotic heart defects with right-to-left shunting reduce pulmonary blood flow, leading to low baseline oxygen saturations. These infants require controlled oxygen delivery to prevent altering pulmonary vascular resistance, and target ranges like 75–85% are typical. The low saturation despite room air and oxygen restriction strongly indicate a right-to-left shunting lesion.

D. An obstructive heart defect: Obstructive defects such as coarctation or pulmonary stenosis may affect perfusion or cause shock, but they do not usually produce stable low oxygen saturation targets like 75–85%. These conditions more commonly lead to poor pulses or blood pressure variability.

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Correct Answer is ["C"]

Explanation

Rationale:

Blood Pressure 148/88 mm Hg: This reading is elevated for a pediatric/adolescent client and indicates stage 2 hypertension based on pediatric BP percentiles. Persistent elevated BP can increase the risk for cardiovascular complications, end-organ damage, and warrants prompt evaluation and intervention.
Heart rate 75/min: This is within normal limits for an adolescent (60–100/min), indicating no acute concern.
Pulse oximetry 98% on room air: Oxygen saturation is within the normal range (95–100%), so no immediate follow-up is needed.
Height 154.9 cm (61 inches): Growth appears consistent with previous measurements; no acute concern is present.
Weight 44.5 kg (98 lb): Weight increase is gradual over time and not outside expected growth patterns, requiring routine monitoring rather than urgent follow-up.

A. Elevated systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities B. Elevated systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities C. Low systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities D. Low systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities

Correct Answer is B

Explanation

Rationale:

A. Elevated systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities: Uniformly elevated blood pressure in both upper and lower extremities does not indicate coarctation of the aorta. This pattern may suggest systemic hypertension but not a localized obstruction of the aorta.

B. Elevated systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities: This is characteristic of coarctation of the aorta, where narrowing of the aortic arch causes obstruction to blood flow to the lower extremities. The upper extremities receive blood before the narrowing, resulting in higher pressures compared with the legs.

C. Low systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities: Low pressures in all extremities suggest generalized hypotension or poor cardiac output rather than a localized structural defect like coarctation of the aorta.

D. Low systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities: This pattern is not consistent with coarctation of the aorta. Elevated lower extremity pressure with low upper extremity pressure may indicate other rare circulatory anomalies but is not typical for this condition.

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The nurse reviews the orders and identifies this infant most likely has which of the following?

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Naxlex Comprehensive Predictor Exams

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Select all that apply. Heart rate 75/min Pulse oximetry 98% on room air Blood Pressure 148/88 mm Hg Height 154.9 cm (61 inches) Weight 44.5 kg (98 lb)

Correct Answer is ["C"]

Explanation

A nurse is completing an assessment of a newborn, including obtaining blood pressure measurements at each extremity. Which of the following findings suggests coarctation of the aorta?

Correct Answer is B

Explanation

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