A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
Cyanosis with crying
Weak pulses
Chronic hypoxemia
Machine-like murmur
The Correct Answer is D
A. Cyanosis with crying: Cyanosis is less common in isolated PDA and more indicative of other congenital heart defects. PDA usually results in increased pulmonary blood flow and may not directly cause cyanosis, especially in less severe cases.
B. Weak pulses: PDA typically causes increased pulmonary blood flow and can result in bounding pulses rather than weak ones. Weak pulses are more indicative of reduced cardiac output, which is not characteristic of PDA.
C. Chronic hypoxemia: Chronic hypoxemia is less associated with PDA and more common in cyanotic heart defects where oxygenated and deoxygenated blood mix. PDA primarily affects the volume of blood flow to the lungs and may not lead to hypoxemia unless complicated by other conditions.
D. Machine-like murmur: A characteristic feature of PDA is a continuous, machine-like murmur caused by turbulent blood flow between the aorta and the pulmonary artery. This murmur is a hallmark sign of PDA and is typically heard during auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stand above the child's eye level when speaking: The nurse should be at eye level with the child to facilitate lip reading and better communication.
B. Talk directly into the child's impaired ear: This can be uncomfortable and is not effective. The nurse should speak directly to the child, allowing them to use any residual hearing or hearing aids.
C. Speak loudly to the child: Speaking loudly can distort the sounds and make understanding more difficult for hearing-impaired individuals.
D. Speak slowly while facing the child: Speaking slowly and facing the child ensures that they can read lips and facial expressions, which aids in understanding.
Correct Answer is C
Explanation
A. Restrain the child's arms. Restraining the child's arms is unsafe and can cause injury. It is important to allow the seizure to occur without interference, except to ensure the child’s safety.
B. Insert a padded tongue blade into the child's mouth. This is an outdated and incorrect practice. Inserting anything into a seizing child's mouth can cause injury to the mouth or teeth and poses a choking hazard.
C. Place the child in a side-lying position. This is the correct action as it helps maintain an open airway and allows for drainage of saliva or vomit, reducing the risk of aspiration.
D. Elevate the child's legs on a pillow. This is not an appropriate action during a seizure as it does not address the safety and airway management needs of the child. Keeping the child on their side is more important for airway safety.
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