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
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Identity versus role confusion is typically associated with adolescence.
B. Autonomy versus a sense of shame and doubt is associated with the toddler years.
C. Initiative versus guilt.
Erikson's theory of psychosocial development includes various stages, and each stage corresponds to a specific age range and a unique psychosocial challenge. The preschool age group, typically from around 3 to 6 years old, is associated with the stage of "Initiative versus guilt." During this stage, children begin to explore their environment, take on new challenges, and start to develop a sense of initiative. They seek to make choices, set goals, and make plans, which is a crucial aspect of their development during the preschool years. However, if their efforts are met with excessive criticism or control, they may develop feelings of guilt.
D. Trust versus mistrust is associated with infancy.
Correct Answer is A
Explanation
Hemophilia is a genetic bleeding disorder in which the blood does not clot properly. It primarily affects the coagulation factors responsible for clot formation. In individuals with hemophilia, bleeding tends to occur most commonly in the joints, particularly in the large weight-bearing joints like the knees, elbows, and ankles. This is known as hemarthrosis and can lead to significant pain and joint damage.
While bleeding in other areas of the body can occur in hemophilia, such as the muscles or soft tissues, joint bleeding is one of the hallmark features of the condition.
The other options, B (intestines), C (brain), and D (pericardium), are less commonly associated with bleeding in hemophilia. Although bleeding can occur in various locations, joint bleeding is the most characteristic and commonly seen manifestation in individuals with hemophilia.
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