A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Frequent nosebleeds

Increased intracranial pressure

Upper extremity hypotension

Weak femoral pulses

Answer and Explanation

The Correct Answer is D

A. Frequent nosebleeds: While hypertension can occur in coarctation of the aorta, frequent nosebleeds are not a typical finding associated with this condition.

B. Increased intracranial pressure: This is not a direct finding of coarctation of the aorta. Increased intracranial pressure may be related to other conditions, but it is not specifically expected in this context.

C. Upper extremity hypotension: In coarctation of the aorta, the upper extremities usually experience higher blood pressure due to the narrowing of the aorta distal to the branches supplying the arms. Therefore, hypotension in the upper extremities is not expected.

D. Weak femoral pulses: This is an expected finding in coarctation of the aorta, as the narrowing of the aorta can lead to decreased blood flow to the lower body, resulting in weak or diminished femoral pulses compared to the upper extremities.

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Correct Answer is A

Explanation

A. "Offer to take pictures of the newborn for the client.": This is a compassionate and supportive action. Offering to take pictures can help the parents create memories and can be an important part of the grieving process, allowing them to acknowledge their loss.

B. "Assure the client that she can have additional children.": While this may be intended to provide comfort, it can minimize the current loss and may not be what the client needs to hear in the moment. It’s important to validate their feelings of grief first.

C. "Avoid talking to the client about the newborn.": Avoiding the topic can make the client feel isolated in their grief. Open discussions about the newborn can help the parents process their emotions and acknowledge their loss.

D. "Discourage the client from allowing friends to see the newborn.": This is not supportive. Allowing friends and family to see the newborn can provide comfort and support to the grieving parents, and should not be discouraged unless there are specific concerns about health or safety.

A. Raise the side rails up when the client is in bed. B. Place the bedside table at the foot of the bed. C. Keep the television on during the night. D. Assist the client to the toilet frequently.

Correct Answer is D

Explanation

A) "Raise the side rails up when the client is in bed.": While raising side rails may provide a sense of security, it can also increase the risk of falls if the client attempts to climb over them. Side rails should be used judiciously and are not always the safest option for clients with dementia.

B) "Place the bedside table at the foot of the bed.": This action can actually increase the risk of injury, as it makes it more difficult for the client to access necessary items, potentially leading to confusion and unsafe movements. Keeping essentials within easy reach can help prevent accidents.

C) "Keep the television on during the night.": While this may provide some comfort, it can also lead to confusion and disrupt sleep patterns for a client with dementia. A calm, quiet environment is generally more conducive to safety and well-being.

D) "Assist the client to the toilet frequently.": This is the most effective action to reduce the risk of injury. Regular assistance to the toilet helps prevent accidents and encourages toileting before the client feels an urgent need, which can lead to falls or confusion. Frequent checks can also help the client maintain dignity and comfort.

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A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

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