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 B
Explanation
A. Once I am fitted for the diaphragm it will always be the correct size. Incorrect because weight changes, pregnancy, or pelvic surgery may require refitting.
B. I need to leave the diaphragm in for six hours after the last act of intercourse. This is correct to ensure that all sperm are inactivated.
C. This contraceptive can be used during menstruation. Incorrect because it's generally not recommended to use the diaphragm during menstruation due to increased risk of infection.
D. I can leave the diaphragm in for a day or two. Incorrect because leaving it in for more than 24 hours can increase the risk of infection, including toxic shock syndrome.
Correct Answer is D
Explanation
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
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