The nurse is performing an admission assessment on the neonate and finds femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be

Place the infant in reverse Trendelenburg position

Place the infant in the knee to chest position

Take the infant's blood pressure in all extremities

Notify the Physician

Answer and Explanation

The Correct Answer is C

Option A (Place the infant in reverse Trendelenburg position) and option B (Place the infant in the knee to chest position) are not the immediate actions to address this situation. While these positions might be used in specific situations, assessing blood pressure is more appropriate in this context to evaluate for potential vascular issues.

Option C. Take the infant's blood pressure in all extremities.

In an infant with weaker femoral pulses compared to the brachial and radial pulses, there might be a concern about coarctation of the aorta (a narrowing of the aorta), which can affect blood flow to the lower extremities. To confirm this and assess for potential issues, taking blood pressure measurements in all four extremities is crucial. This comparison can help identify pressure differentials between the upper and lower extremities, which is a hallmark sign of coarctation of the aorta.

Option D (Notify the Physician) is generally a good step, but taking the blood pressure in all extremities should be done first to provide comprehensive information for the physician when discussing the infant's condition.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

The reticulocyte count is a measure of young, immature red blood cells. An elevated reticulocyte count indicates the bone marrow's ability to respond to anemia by producing new red blood cells.

For an infant, a reticulocyte count of 8% would be an indicator of severe anemia. An elevated reticulocyte count suggests the body is trying to compensate for the decreased number of mature red blood cells by producing more young ones. This is often seen in severe anemia as the body attempts to increase the red blood cell count.

The other options (A, C, and D) represent normal or less severe reticulocyte counts.

A reticulocyte count of 3% is within the normal range.

A reticulocyte count of 0.5% is on the lower side but not as severe as 8%.

A reticulocyte count of 5% indicates a response to anemia but is not as elevated as 8%.

A. Neutropenic B. Droplet C. Bleeding D. Contact

Correct Answer is C

Explanation

A. Neutropenic Precautions: Neutropenia refers to a low neutrophil count, a type of white blood cell responsible for fighting infections. While children with leukemia are at risk for neutropenia due to the disease and its treatment, the primary concern in this scenario is the critically low platelet count and the risk of bleeding. Neutropenic precautions focus on preventing infections.

B. Droplet Precautions: Droplet precautions are used when dealing with respiratory infections that are transmitted through respiratory droplets, such as coughing or sneezing. This is not the primary concern for a child with leukemia and a low platelet count, as the main risk is bleeding due to the low platelet count.

C. Bleeding Precautions: Leukemia, especially in a child with a critically low platelet count, puts the child at a high risk of bleeding. Platelets are essential for blood clotting, and when they are severely decreased, even minor injuries can lead to excessive bleeding. The nurse should take precautions to minimize the risk of bleeding. This includes avoiding invasive procedures, using a soft toothbrush, and ensuring that the child does not participate in activities that could result in injury.

D. Contact Precautions: Contact precautions are used to prevent the transmission of infectious diseases through direct contact. While a child with leukemia may have a weakened immune system and be at risk of infections, the primary concern in this case is the critically low platelet count and the risk of bleeding. Contact precautions are more relevant in cases of contagious diseases where physical contact could transmit the infection.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is performing an admission assessment on the neonate and finds femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following Reticulocyte count is an indicator of severe anemia for an infant?

Correct Answer is B

Explanation

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Correct Answer is C

Explanation

Which is the treatment of choice for severe aplastic anemia?

When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?

Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply.

New foods should be introduced to the infant at intervals of

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Which is the primary goal for a newborn with a cleft of the soft palate?

An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse understands dyspnea occurs because blood

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?