A six-month-old infant is hospitalized for repair of a ventricular septal defect. As you are doing his physical exam, you note that the infant's extremities are cool, he has weak peripheral pulses, and his urine output is diminished. These clinical findings are suggestive of which of the following?
Increased stroke volume
Cardiac arrhythmia
Decreased cardiac output
Cyanosis
The Correct Answer is C
Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.
Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.
Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.
Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.
Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.
Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.
Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.
Correct Answer is A
Explanation
Choice A reason: Using a night-light can provide a sense of security and comfort for a child, especially if they are afraid of the dark. This can help prevent sleep problems by reducing fear and anxiety at bedtime¹.
Choice B reason: While it's true that certain foods can promote sleep, high-carbohydrate snacks before bedtime are not recommended. They can lead to energy spikes and crashes, which can disrupt sleep¹.
Choice C reason: While it's important for the sleep environment to be calming and conducive to sleep, it doesn't always have to be completely quiet and dark. Some children may find a completely dark room scary, and some background noise can actually be soothing¹.
Choice D reason: The need for naps varies greatly among children. Some 4-year-olds may still benefit from an afternoon nap. Eliminating the nap can lead to overtiredness, which can actually make it harder for the child to fall asleep at night¹.
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