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 A
Explanation
A.Growth of that leg may be affected.
When a fracture occurs near the epiphyseal plate of a long bone, such as the femur, there is a risk of damage to the growth plate. The growth plate (epiphyseal plate) is responsible for longitudinal bone growth in children. If the growth plate is injured or damaged during the fracture, it can potentially lead to growth disturbances and affect the growth of that leg.
B. Risk for infection at this location is increased: While any fracture has a risk of infection, the proximity to the epiphyseal plate doesn't necessarily increase the risk of infection.
C. Long bones contain marrow, which increases the risk for anemia: The presence of bone marrow in long bones is unrelated to the potential effects on bone growth after a fracture near the epiphyseal plate.
D. Fracture repair will necessitate prolonged traction: The use of traction for fracture repair can vary depending on the type and location of the fracture. However, the primary concern with a fracture near the epiphyseal plate is its potential impact on bone growth.
Correct Answer is A
Explanation
A. Praise them for the care they are giving their child.
Families facing the impending loss of a child need compassion and support. Praising them for the care they are giving their child acknowledges their efforts and reinforces their role in providing comfort to the child. This can help build trust and rapport between the family and healthcare providers during this difficult time.
B. Informing the family that they should have taken better care of their child is judgmental and hurtful. It does not provide the emotional support the family needs.
C. Telling the family to wait until after the death to discuss feelings is not helpful. Open communication and addressing feelings should be encouraged throughout the process.
D. Telling them that the staff will perform all of the final care may come across as impersonal. Involving the family in the care of their dying child can be an important part of the grieving and healing process.
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