A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following manifestations should the nurse expect?
Machine-like murmur
Severe cyanosis
Decreased blood pressure in the legs
Pulmonary edema
The Correct Answer is C
A. Machine-like murmur:
A machine-like murmur typically refers to a continuous murmur, which can be heard throughout systole and diastole. While machine-like murmurs can be associated with certain cardiac conditions, such as patent ductus arteriosus (PDA), they are not typically heard in coarctation of the aorta. In coarctation of the aorta, a systolic ejection murmur may be heard over the upper left sternal border due to turbulent blood flow across the narrowed aortic segment.
B. Severe cyanosis:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to decreased oxygenation of the blood. While cyanosis can occur in various congenital heart defects, such as tetralogy of Fallot, it is not a characteristic manifestation of coarctation of the aorta. Coarctation of the aorta typically results in decreased blood flow to the lower extremities rather than mixing of oxygenated and deoxygenated blood.
C. Decreased blood pressure in the legs:
This is the correct choice. Coarctation of the aorta is characterized by narrowing of the aorta, which leads to decreased blood flow to the lower extremities. Consequently, blood pressure measurements in the legs may be lower compared to those in the arms. This finding is often a key indicator of coarctation of the aorta.
D. Pulmonary edema:
Pulmonary edema refers to the accumulation of fluid in the lungs and is typically associated with conditions such as heart failure or fluid overload. While some congenital heart defects may lead to heart failure and subsequent pulmonary edema, coarctation of the aorta does not directly cause pulmonary edema. Instead, it primarily affects blood flow to the lower extremities due to the narrowing of the aorta.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Applying suction for 20 seconds:
Suctioning for 20 seconds is within the recommended duration for endotracheal suctioning in children. It allows adequate time for removing secretions without causing excessive trauma to the airway.
B. Introducing the catheter without suction:
This action is incorrect. When performing endotracheal suctioning, the catheter should be introduced into the endotracheal tube while applying suction. Introducing the catheter without suction may not effectively remove secretions and can lead to ineffective suctioning.
C. Rotating the catheter between the thumb and forefinger while suctioning:
Rotating the catheter between the thumb and forefinger while suctioning helps to prevent the catheter from sticking to the airway walls and facilitates the removal of secretions. This action is appropriate and helps ensure effective suctioning.
D. Allowing the child to rest for 30 to 60 seconds between suctioning passes:
Allowing the child to rest between suctioning passes helps minimize hypoxia and discomfort during the procedure. This action is appropriate and ensures that the child has adequate time to recover before the next suctioning pass.
Correct Answer is C
Explanation
A. Coloring book with crayons:
Coloring activities with crayons are typically more suitable for older children who have developed fine motor skills and hand-eye coordination. At 10 months old, infants are still in the early stages of motor development and may not have the dexterity to hold and manipulate crayons effectively. Additionally, infants at this age are more likely to put objects in their mouths, which poses a choking hazard with crayons.
B. Large-piece puzzles:
Puzzles with large pieces can be beneficial for older children's cognitive development by promoting problem-solving skills and hand-eye coordination. However, at 10 months old, infants are still developing their motor skills and may not have the ability to manipulate puzzle pieces effectively. Puzzles with small pieces can also pose a choking hazard for infants.
C. Crib gym:
A crib gym is a suitable toy for a 10-month-old infant as it provides opportunities for visual stimulation, reaching, grasping, and hand-eye coordination development. Crib gyms typically consist of hanging toys or objects that the infant can bat at or grasp while lying in their crib or playpen. This type of toy encourages exploration and interaction while ensuring safety within the confines of the crib.
D. Put-in take-out toy:
Put-in take-out toys involve placing objects into a container and then removing them, which can be engaging for infants. However, while this type of toy may provide some entertainment for a 10-month-old, it may not offer as much visual and tactile stimulation as a crib gym. Additionally, some put-in take-out toys may have smaller parts that pose a choking hazard for infants, so careful supervision is necessary.
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