The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities. Which assessment will the nurse perform next on this infant?
Pedal pulses.
Blood pressure of the four extremities.
Lower extremity reflexes.
Hemoglobin and hematocrit values.
The Correct Answer is B
Choice A reason: Assessing pedal pulses is important, but it does not provide complete information about the circulatory status of the infant.
Choice B reason: This is the correct choice. Discrepancies in pulse strength between the upper and lower extremities may indicate a cardiovascular problem such as coarctation of the aorta, which can be further evaluated by comparing blood pressures in all four extremities.
Choice C reason: Lower extremity reflexes are not directly related to the strength of pulses.
Choice D reason: Hemoglobin and hematocrit values are important but would not be the next step in assessing the significance of the difference in pulse strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A reason: While a disturbed body image can impact psychological well-being, it is not the immediate priority in the acute phase of burn management.
Choice B reason: Ineffective airway clearance due to edema from burns to the face and chest poses an immediate threat to life, requiring urgent attention to maintain breathing.
Choice C reason: The risk for infection is a significant concern due to epidermal damage; however, it follows airway management in terms of immediate priorities.
Choice D reason: Impaired urinary elimination may occur due to fluid shifts after burns, but ensuring effective airway clearance is the most critical initial step in care.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Hypopituitarism often results in short stature due to a deficiency in growth hormone.
Choice B reason: Precocious puberty is not typically associated with hypopituitarism; it is more often related to excess hormone production.
Choice C reason: Progressive linear growth retardation after normal growth in the first five years is not characteristic of hypopituitarism.
Choice D reason: While stunted growth can occur, hypopituitarism specifically affects height due to growth hormone deficiency, and weight may not be equally affected.
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