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An infant who has coarctation of the aorta
A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following manifestations should the nurse expect?
- A. Machine-like murmur
- B. Severe cyanosis
- C. Decreased blood pressure in the legs
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to decreased blood flow to the lower body. This results in decreased blood pressure in the legs due to reduced perfusion. A machine-like murmur (A) is typically associated with patent ductus arteriosus. Severe cyanosis (B) is more commonly seen in conditions like Tetralogy of Fallot. Pulmonary edema (D) is often seen in congestive heart failure.
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An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
An infant who has spina bifida
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?
- A. Place the infant in prone position.
- B. Cover the infant's lesion with a dry cloth.
- C. Feed the infant through an NG tube.
- D. Diapering over a low defect will keep the infant free from infection
Correct Answer: D
Rationale: The correct answer is D. Diapering over a low defect will keep the infant free from infection. This is because keeping the area covered with a diaper helps prevent contamination and infection. Placing the infant in prone position (choice A) is not recommended as it can put pressure on the lesion. Covering the lesion with a dry cloth (choice B) may not provide adequate protection from contamination. Feeding the infant through an NG tube (choice C) is not directly related to preventing infection at the lesion site. Therefore, the best option is to diaper over the defect to maintain hygiene and prevent infection.
A child who has Kawasaki disease
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?
- A. Respiratory
- B. Gastrointestinal
- C. Cardiovascular
- D. Integumentary
Correct Answer: C
Rationale: The correct answer is C: Cardiovascular. Kawasaki disease primarily affects the cardiovascular system, causing inflammation of blood vessels, particularly the coronary arteries. This can lead to complications such as coronary artery aneurysms and myocarditis. The other choices are incorrect because Kawasaki disease does not primarily affect the respiratory, gastrointestinal, or integumentary systems. The key feature of Kawasaki disease is the inflammation of blood vessels, which is why the cardiovascular system is the primary system affected.
A toddler who has laryngotracheobronchitis
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?
- A. Decreased stridor
- B. Increased restlessness
- C. Decreased heart rate
- D. Decreased temperature
Correct Answer: B
Rationale: The correct answer is B: Increased restlessness. Restlessness is a common sign of airway obstruction in toddlers with laryngotracheobronchitis. As the airway becomes more obstructed, the toddler may feel increasingly anxious and agitated, leading to increased restlessness. Monitoring for this sign is crucial as it indicates worsening respiratory distress and the need for prompt intervention.
Decreased stridor (choice A) is not indicative of airway obstruction in this condition, as stridor is a high-pitched sound heard on inspiration and can be present in both mild and severe cases of laryngotracheobronchitis. Decreased heart rate (choice C) and decreased temperature (choice D) are not typically associated with airway obstruction and are less relevant in this context.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.