What assessment finding would the nurse expect in an infant with coarctation of the aorta?
Point of maximum impulse is shifted to the right
Weak or absent lower extremity pulses
Apical pulse is greater than radial pulse
Systolic murmur at the left sternal border
The Correct Answer is B
A. Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. I'll expect the plastic ring to fall off by itself within a week. This is correct; the Plastibell ring typically falls off within 5-8 days.
B. I'll apply petroleum jelly to his penis with diaper changes. Incorrect for Plastibell, because the plastic ring itself protects the site, and petroleum jelly can interfere with healing.
C. I'll make sure his diaper is loose in the front. This helps avoid pressure and irritation on the circumcised area.
D. I'll wash his penis with warm water and mild soap each day. Incorrect; the area should be kept clean but only water should be used to avoid irritation.
E. I'll call the doctor if I see any bleeding. Any significant bleeding should be reported to the healthcare provider immediately.
Correct Answer is A
Explanation
A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.
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