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.
Pulse oximetry reading within defined limits.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Acetaminophen is a common medication that can be administered for pain relief and fever reduction. It is often used in a variety of clinical settings, including after the placement of an IV line.
Choice B rationale
Morphine is a strong opioid medication used to treat severe pain. It may be ordered after the placement of an IV line, especially if the patient is experiencing significant discomfort.
Choice C rationale
Aspirin is a medication that can be used for pain relief, fever reduction, and as an antiinflammatory. It may be ordered in a variety of clinical scenarios, including after the placement of an IV line.
Choice D rationale
Albuterol is a bronchodilator used to treat or prevent bronchospasm in people with reversible obstructive airway disease. It is not typically administered following the placement of a 5% dextrose intravenous line unless the patient has a pre-existing respiratory condition.
Choice E rationale
Racemic epinephrine is used to treat croup and asthma attacks. It is not typically administered following the placement of a 5% dextrose intravenous line unless the patient has a pre-existing respiratory condition.
Correct Answer is D
Explanation
Choice A rationale
While multiple gestation can cause an increase in maternal serum alpha-fetoprotein (MS-AFP) levels, it is not the most likely cause of an elevated MS-AFP level at 17 weeks.
Choice B rationale
Fetal hypoxia, or lack of oxygen to the fetus, is not typically associated with an increase in MSAFP levels.
Choice C rationale
Down syndrome is typically associated with lower, not higher, levels of MS-AFP891011.
Choice D rationale
An elevated level of MS-AFP at 17 weeks is most commonly associated with a neural tube defect. Neural tube defects are birth defects of the brain, spine, or spinal cord that occur during the first month of pregnancy.
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