The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

Ventricular septal defect (VSD) has audible murmurs.

Patent ductus arteriosus is fatigued after feeding

Coarctation of aorta has an elevated blood pressure in the upper extremity.

Tetralogy of Fallot (TOF) with hypercyanotic (Tet) spells is crying.

Answer and Explanation

The Correct Answer is D

Choice A rationale

An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.

Choice B rationale

Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.

Choice C rationale

Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.

Choice D rationale

A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.

Choice B rationale

Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.

Choice C rationale

Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.

Choice D rationale

Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.

A. Diaphragmatic respirations. B. Bilateral bronchial breath sounds. C. Flaring of the nares. D. A resting respiratory rate of 35 breaths/minute.

Correct Answer is C

Explanation

Choice A rationale

Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.

Choice B rationale

Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.

Choice C rationale

Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.

Choice D rationale

A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

Correct Answer is D

Explanation

A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Correct Answer is C

Explanation

A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?