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 B
Explanation
A. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.
Correct Answer is D
Explanation
A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.
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