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.

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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.

A. Alertness as such weight loss is not expected B. Reassurance as this is a normal weight loss C. Alarm as this is a drastic weight loss D. Concern as this may be an indicator of inadequate nutrition

Correct Answer is B

Explanation

A. Alertness as such weight loss is not expected: This response may unnecessarily alarm the mother when, in fact, some weight loss in the early days is normal.

B. Reassurance as this is a normal weight loss.

It is normal for newborns to lose some weight during the first few days of life. The loss is often related to fluid loss, changes in feeding patterns, and initial adjustment to life outside the womb. A loss of one-half pound in a 2-day-old neonate is generally considered within the normal range. It's important for the nurse to reassure the new mother that this weight loss is expected and not a cause for alarm. Newborns typically start to regain their birth weight within a week or two. This reassurance can help ease the mother's distress and anxiety.

C. Alarm as this is a drastic weight loss: Characterizing this weight loss as "drastic" is not accurate or helpful and would likely increase the mother's anxiety.

D. Concern as this may be an indicator of inadequate nutrition: Jumping to the conclusion of inadequate nutrition without further assessment and evidence is premature and may unnecessarily worry the mother. It's important to start with reassurance and then investigate if there are concerns about nutrition.

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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

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

The new mother of a 2-day-old neonate who weighed 8 pounds at birth is distressed that the baby has lost one-half pound. The home health nurse's response is one of:

Correct Answer is B

Explanation

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