When assessing a child for possible congenital heart defects (CHDsl, where should the nurse measure blood pressure?
The right arm
The left arm
All four extremities
Both arms while the child is crying
The Correct Answer is C
A. The right arm: Measuring blood pressure in only one arm can miss important pressure discrepancies that occur with certain congenital heart defects, particularly those involving obstruction of systemic blood flow. Upper-extremity readings alone do not provide a complete hemodynamic picture.
B. The left arm: While the left arm may reflect systemic circulation, isolated measurement does not allow comparison between upper and lower extremities, which is essential for detecting defects such as coarctation of the aorta. A single-site reading limits diagnostic value.
C. All four extremities: Congenital heart defects, especially coarctation of the aorta, often cause higher blood pressure in the arms and lower pressure in the legs due to narrowing of the aorta distal to the subclavian arteries. Measuring all four extremities allows detection of pressure gradients that strongly suggest CHDs.
D. Both arms while the child is crying: Crying can falsely elevate blood pressure due to sympathetic stimulation and does not provide reliable or comparative data. Additionally, measuring only the arms fails to assess lower-extremity perfusion differences critical in CHD evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the infant in the knee-chest position: In a hypercyanotic (“Tet”) spell, placing the infant in a knee-chest position increases systemic vascular resistance, reduces right-to-left shunting, and improves pulmonary blood flow and oxygenation. Immediate positioning is a first-line emergency intervention.
B. Start an IV for fluids: Establishing IV access is important for administering medications and fluids, but it is secondary to immediate measures to relieve cyanosis and improve oxygenation during a Tet spell.
C. Prepare the infant for surgery: Surgical repair is definitive treatment for tetralogy of Fallot, but emergent stabilization takes priority before operative intervention can occur.
D. Raise the head of the bed: Elevating the head may aid comfort and respiratory mechanics in some conditions, but it does not address the acute pathophysiology of right-to-left shunting causing cyanosis during a Tet spell.
Correct Answer is D
Explanation
A. The child has above-normal growth for his age: Congenital hypothyroidism typically results in slowed growth and delayed skeletal maturation due to insufficient thyroid hormone. Above-normal growth is not consistent with this condition and would be unexpected.
B. The child is active and playful: Hypothyroidism in infants usually causes lethargy, hypotonia, and decreased activity. A highly active and playful infant would be atypical and not indicative of untreated congenital hypothyroidism.
C. The skin is pink and healthy looking: Infants with congenital hypothyroidism often have pale, dry, or mottled skin due to decreased metabolism and poor perfusion. Healthy, rosy skin is not a common finding in this condition.
D. It is difficult to keep the child awake: Lethargy and excessive sleepiness are hallmark signs of congenital hypothyroidism in infants. Difficulty keeping the infant awake reflects central nervous system depression caused by thyroid hormone deficiency and is a key clinical indicator.
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