The nurse is caring for a newborn diagnosed with patent ductus arteriosus. What assessment findings would be consistent with this diagnosis? (Select All that Apply.)
Circumoral cyanosis
Tachycardia
Elevated diastolic blood pressure
Bradycardia
Bounding peripheral pulses
Continuous murmur
Narrow pulse pressure
Correct Answer : B,E,F
A. Circumoral cyanosis. This can occur but is less specific for PDA and more related to general issues with oxygenation.
B. Tachycardia. PDA can lead to increased heart rate as the heart works harder to manage the increased blood flow.
C. Elevated diastolic blood pressure. PDA usually causes a decrease in diastolic pressure, not an increase.
D. Bradycardia. Bradycardia is not typically associated with PDA.
E. Bounding peripheral pulses. PDA allows more blood to flow into the systemic circulation, leading to stronger pulses.
F. Continuous murmur. PDA typically causes a continuous "machine-like" murmur because of the continuous flow of blood from the aorta to the pulmonary artery.
G. Narrow pulse pressure. PDA often causes a wide pulse pressure, not a narrow one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Correct Answer is D
Explanation
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
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