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A nurse on a pediatric unit is caring for a 5-week-old infant.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

2000:

Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist.

2200:

Infant asleep in crib. Heart rate regular, no murmur on auscultation.

Vital Signs

2000:

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Temperature 37° C (98.6° F)

Oxygen saturation 97% on room air, right wrist

Trunk, arms, and hands warm to palpation

Edema noted to hands, feet, and periorbital area

Weak bilateral femoral pulses

Lower extremities cool to palpation

Mucous membranes pink and moist

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Answer and Explanation

The Correct Answer is ["B","C","D","F"]

Findings that require follow-up:

Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Applying heat to the affected areas: Heat application promotes vasodilation and helps relieve pain in vaso-occlusive crises. This is a priority because managing pain is critical during a crisis. It can also help improve blood flow and alleviate discomfort.
B. Administering prophylactic antibiotics: While prophylactic antibiotics are important in preventing infections in sickle cell anemia, this is not the immediate priority during a vaso-occlusive crisis.
C. Administering the pneumococcal vaccine: While vaccination is important, it is not a priority during a vaso-occlusive crisis.
D. Promoting bed rest: Bed rest is generally recommended to reduce energy expenditure, but it does not directly address the acute pain or vaso-occlusion that needs to be managed immediately.

A. Flat anterior fontanel B. Dry, hot skin C. Loss of 5% of weight D. Absence of tears when crying

Correct Answer is D

Explanation

A. "Flat anterior fontanel." A sunken anterior fontanel, not flat, is a sign of severe dehydration in infants.
B. "Dry, hot skin." Dry skin is a symptom of dehydration, but "hot" skin may indicate fever rather than severe dehydration.
C. "Loss of 5% of weight." A 5% weight loss indicates mild dehydration; severe dehydration is characterized by a weight loss of 10% or more.
D. "Absence of tears when crying." Absence of tears is a reliable indicator of severe dehydration in infants.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?

Correct Answer is D

Explanation

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