The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?
Ventricular septal defect (VSD) has audible murmurs.
Patent ductus arteriosus is fatigued after feeding
Coarctation of aorta has an elevated blood pressure in the upper extremity.
Tetralogy of Fallot (TOF) with hypercyanotic (Tet) spells is crying.
The Correct Answer is D
Choice A rationale
An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.
Choice B rationale
Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.
Choice C rationale
Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.
Choice D rationale
A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.
Choice B rationale
Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.
Choice C rationale
Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.
Choice D rationale
Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.
Correct Answer is A
Explanation
Choice A rationale
A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.
Choice B rationale
Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.
Choice C rationale
Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.
Choice D rationale
Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.
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