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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Keep the client's leg in a dependent position. Keeping the leg in a dependent position can increase swelling and delay healing. The leg should be elevated to reduce swelling and promote circulation.

B. Use a hair dryer on a hot setting to dry the cast. Using a hair dryer on a hot setting can cause burns and does not effectively dry a plaster cast. Plaster casts take time to dry and should be air-dried naturally.

C. Discourage the client from ambulating: Early mobilization is encouraged to prevent complications like muscle atrophy and joint stiffness, as long as it is safe and the healthcare provider has approved it. Completely discouraging ambulation is not generally recommended unless specified by a doctor.

D. Perform a neurovascular check of the lower extremities. Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast. This includes checking for pain, pallor, pulse, paresthesia, and paralysis (the 5 P’s). This helps detect complications like compartment syndrome or decreased circulation early.

A. "Bring your infant into the clinic today to be seen." B. "You might want to try switching to a different formula." C. "Give your infant an oral rehydration solution." D. "Burp your child more frequently during feedings."

Correct Answer is A

Explanation

A. "Bring your infant into the clinic today to be seen." This is the appropriate response. Projectile vomiting can be a sign of pyloric stenosis, a condition that requires prompt medical evaluation and potential surgical intervention.

B. "You might want to try switching to a different formula." While switching formula might be considered for minor feeding issues, projectile vomiting is severe and warrants immediate medical attention rather than a dietary change.

C. "Give your infant an oral rehydration solution." Oral rehydration might be useful for dehydration, but it does not address the underlying cause of projectile vomiting, which needs to be diagnosed and treated by a healthcare professional.

D. "Burp your child more frequently during feedings." Although burping can help with mild spit-ups, projectile vomiting is a more serious symptom that requires medical evaluation rather than just a change in feeding practices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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