The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
Hemiplegia.
Fever.
Vigorous feeding and satiation.
Hypotension and tachycardia.
The Correct Answer is D
Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood flow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate fluid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.
Option A is not a typical finding associated with aortic stenosis.
Option B is not directly related to the infant's cardiac condition.
Option C is not a typical finding associated with heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Correct Answer is C
Explanation
The nurse should report chest pain to the healthcare provider immediately when caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Chest pain can be a sign of acute chest syndrome, a potentially life-threatening complication of sickle cell disease that requires prompt treatment.
Swelling in the hands or feet, ulcers on the legs, and jaundice are common symptoms of sickle cell disease and do not require immediate reporting to the healthcare provider.
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