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 ["A","C","E"]
Explanation
A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.
Correct Answer is A
Explanation
A. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.
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