A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply.)
Clubbing of the fingers
Weak femoral pulses
Cool skin of lower extremities
Low blood pressure
Severe cyanosis
Correct Answer : B,C
Choice A reason: Clubbing of the fingers is not typically associated with coarctation of the aorta; it is more commonly seen in chronic hypoxia conditions.
Choice B reason: Weak femoral pulses are expected in coarctation of the aorta due to the narrowing of the aorta, which can reduce blood flow to the lower extremities.
Choice C reason: Cool skin of the lower extremities can be a result of decreased blood flow due to the narrowed aorta in coarctation.
Choice D reason: High blood pressure is more commonly associated with coarctation of the aorta, especially in the upper body, due to the narrowing of the aorta increasing resistance to blood flow⁷.
Choice E reason: Severe cyanosis can occur in coarctation of the aorta if there is a significant obstruction to blood flow, leading to poor oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Separation anxiety is common in early childhood and typically resolves as the child develops, usually by around age 2 or 3.However, it can also be present in school-age children, especially if it develops into separation anxiety disorder.
Choice B reason: This is not typically included in teaching about separation anxiety. Detachment might be a response to prolonged separation or hospitalization, but it is not a stage of separation anxiety.
Choice C reason:
While kicking a stranger can be a manifestation of separation anxiety, it’s more constructive to focus on common symptoms such as excessive worry when apart from home or family, or panic and fear at the time of separation
Choice D reason: Separation anxiety that is severe and persistent can lead to challenges in adaptability and functioning. It’s important for caregivers to recognize symptoms and seek help if the anxiety interferes with daily life.
Correct Answer is B
Explanation
Choice A reason: Hypoventilation is a late sign of hypoxemia and is characterized by an abnormally slow breathing rate, reducing oxygen intake and increasing carbon dioxide in the blood.
Choice B reason: Tachypnea, or rapid breathing, is an early sign of hypoxemia as the body attempts to increase oxygen levels by breathing more quickly.
Choice C reason: A nonproductive cough is not directly related to hypoxemia, which is a deficiency in the amount of oxygen reaching the tissues.
Choice D reason: Nasal stuffiness is not a specific indicator of hypoxemia and can be associated with various conditions.
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