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. The child: The primary focus of the physical examination is the child’s current health status, including assessment of all body systems. The examination aims to identify any deviations from normal growth, development, or function, and to correlate findings with the history provided.
B. The parents: While parents provide essential information regarding the child’s health, behaviors, and history, they are not the focus of the physical examination. Their role is to assist with history-taking and contextual information.
C. Chief complaint: The chief complaint guides the assessment and helps prioritize certain systems, but a comprehensive physical examination should extend beyond the presenting problem to evaluate overall health and detect any additional issues.
D. Developmental age: Assessing developmental age is part of the examination to compare expected growth and milestones with chronological age, but it is one component rather than the central focus, which remains the child’s overall physical condition.
Correct Answer is A
Explanation
A. Unruptured membranes: Internal fetal monitoring devices, such as a fetal scalp electrode or intrauterine pressure catheter, require rupture of membranes to access the amniotic fluid and fetal scalp. Attempting insertion with intact membranes increases the risk of trauma, infection, and procedural failure.
B. Cervix is dilated to 4 cm: A cervical dilation of 4 cm is typically sufficient for safe internal monitoring once membranes are ruptured. The degree of dilation itself does not prevent application, provided other criteria for internal monitoring are met.
C. External monitors are currently being used: External monitoring is noninvasive and can be used concurrently or as an initial step. The presence of external monitors does not contraindicate internal monitoring; internal devices are considered when more accurate fetal heart rate or contraction data are needed.
D. Fetus has a known heart defect: Some fetal heart defects may alter baseline heart rate or variability but do not automatically preclude the use of internal monitoring devices. Internal monitoring can still be applied safely if membranes are ruptured and other clinical criteria are met.
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