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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Iron-rich foods that should be recommended for a toddler with iron deficiency anemia include:
B. Chicken: Chicken, especially dark meat, is a good source of heme iron, which is easily absorbed by the body.
C. Lean Steak: Lean beef, such as steak, is also a good source of heme iron.
Non-heme iron from plant-based sources is also beneficial but is generally less easily absorbed. So, the following options are non-heme iron sources:
A. Broccoli: While broccoli contains iron, it is a non-heme iron source. It can still contribute to iron intake, but it's not as efficient as heme iron from animal sources.
D. Carrots: Similar to broccoli, carrots contain non-heme iron, but they can be part of a balanced diet for increasing iron intake.
E. Whole Milk: Whole milk can interfere with iron absorption in the body. It's not recommended for children with iron deficiency anemia, as it can make the condition worse. It's better to choose lower-fat milk or alternative milk sources.
Additionally, other sources of iron-rich foods for toddlers can include fortified cereals, legumes (like lentils and beans), and fortified infant formulas if needed. Always consult with a healthcare provider for specific dietary recommendations based on the child's condition.
Correct Answer is D
Explanation
A. Diabetes Insipidus is associated with reduced ADH levels, leading to excessive urination and dehydration, not hyponatremia.
B. Acromegaly results from excessive growth hormone (not ADH) secretion, causing abnormal growth of tissues and bones.
C. Addison's disease involves the adrenal glands and the insufficient production of cortisol and aldosterone, not ADH-related hyponatremia.
D. Syndrome of Inappropriate Antidiuretic Hormone (SIADH).
SIADH is a disorder characterized by the excessive release of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to increased water reabsorption by the kidneys. This results in diluted blood and hyponatremia (low sodium levels) due to the retention of water. Patients with SIADH often experience fluid overload and related symptoms.
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