The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse expect?

Blood pressure variance across extremities.

Hypotension.

Tachycardia.

Pulse oximetry reading within defined limits.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Blood pressure variance across extremities is not typically associated with unrepaired ventricular septal defect and heart failure in a toddler.

Choice B rationale

Hypotension is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.

Choice C rationale

Tachycardia, or a fast heart rate, is a common symptom in toddlers with unrepaired ventricular septal defect and heart failure. This is because the heart has to work harder to pump blood through the body.

Choice D rationale

While a pulse oximetry reading within defined limits is ideal, it is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.

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Correct Answer is B

Explanation

Choice A rationale
Immunocompromised children are generally not given live virus vaccines due to the risk of developing the disease the vaccine is meant to prevent.
Choice B rationale
This is the correct statement. If a child has a fever or is ill, vaccination may be postponed.
Choice C rationale
Second doses of vaccines are generally not given to children who have had allergic reactions to the first dose.
Choice D rationale
Breastfeeding does not interfere with the effectiveness of vaccines. In fact, breastfeeding can enhance the response to certain vaccine antigens.

A. To prevent herpes infection B. To prevent eye infections C. To clear the infant’s vision D. To dilate the pupil so the red reflex can be visualized E. To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

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The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse expect?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing information to a parent of a six-month old about vaccinations. Which statement made by the parent should the nurse recognize as understanding the information?

Correct Answer is B

Explanation

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

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The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse expect?