A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
Machine like murmur
Chronic hypoxemia
Cyanosis with crying
Weak pulse
The Correct Answer is A
A. Machine-like murmur.
This option is correct. A characteristic clinical manifestation of a large patent ductus arteriosus is a continuous "machine-like" murmur heard on auscultation. This murmur is typically heard best at the upper left sternal border and may radiate to the back.
B. Chronic hypoxemia.
Chronic hypoxemia is not typically a primary manifestation of a large PDA. While PDA can lead to increased pulmonary blood flow and potentially contribute to pulmonary congestion, chronic hypoxemia may not be a prominent feature unless complications such as heart failure develop.
C. Cyanosis with crying.
Cyanosis with crying is more commonly associated with cyanotic congenital heart defects such as tetralogy of Fallot. While PDA can contribute to cyanosis in certain circumstances, it is not typically a consistent clinical manifestation.
D. Weak pulse.
A weak pulse is not typically associated specifically with a large PDA. Infants with PDA may have bounding pulses due to increased blood flow through the ductus arteriosus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Upright: This position allows for better expansion of the lungs and improved ventilation-perfusion matching, as gravity helps the diaphragm move downward and expand the lungs. It is often beneficial for patients with respiratory distress or failure.
B. Supine: While lying flat on the back (supine position) may be comfortable for some patients, it can restrict lung expansion, especially in individuals with compromised respiratory function. This position may not be ideal for maximal lung expansion in this scenario.
C. Prone: The prone position involves lying flat on the abdomen. In some cases, especially in adults with acute respiratory distress syndrome (ARDS), prone positioning has been shown to improve oxygenation by optimizing lung mechanics. However, it may not be practical or comfortable for all patients and is not typically used as a first-line intervention in school-age children with pneumonia.
D. Side-lying: While side-lying positions can sometimes improve lung expansion on the dependent side, it may not be as effective as the upright position in maximizing lung expansion, especially in cases of respiratory failure.
Correct Answer is B
Explanation
A. Drooling:
Drooling can occur post-tonsillectomy due to throat discomfort or swelling. However, it is not specific to hemorrhage. It may result from pain, swelling, or difficulty swallowing.
B. Continuous swallowing:
Continuous swallowing is indeed a clinical manifestation of hemorrhage after a tonsillectomy. The presence of blood in the throat triggers the swallowing reflex, leading to frequent swallowing by the patient. This symptom is characteristic of hemorrhage and requires immediate medical attention.
C. Poor fluid intake:
Poor fluid intake can occur post-tonsillectomy due to pain, discomfort, or nausea. While it can be a concern for overall recovery, it is not specific to hemorrhage.
D. Increased pain:
Increased pain can be associated with hemorrhage, especially if it is sudden, severe, or worsening. However, it is not as specific as continuous swallowing in indicating hemorrhage post-tonsillectomy. Increased pain can also be due to various other reasons such as inflammation, infection, or trauma.
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