A nurse is assessing a young child and suspects coarctation of the aorta based on which finding?
Diastolic murmur.
Hypotension.
Excessive crying.
Unequal upper and lower extremity pulses.
The Correct Answer is D
Choice A rationale
A diastolic murmur is not a typical finding in coarctation of the aorta. This condition is more commonly associated with systolic murmurs.
Choice B rationale
Hypotension is not a common finding in coarctation of the aorta. In fact, hypertension in the upper extremities is more typical due to the narrowing of the aorta.
Choice C rationale
Excessive crying is not a specific indicator of coarctation of the aorta. It can be a symptom of many different conditions and is not diagnostic.
Choice D rationale
Unequal upper and lower extremity pulses are a key finding in coarctation of the aorta. The narrowing of the aorta causes reduced blood flow to the lower extremities, resulting in weaker pulses compared to the upper extremities.
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Correct Answer is C
Explanation
Choice A rationale
Keeping the child flat and applying pressure to the bridge of the nose is not effective for managing a nosebleed. The child should be in an upright position to reduce blood flow to the nose and prevent swallowing blood.
Choice B rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended approach for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose.
Choice C rationale
Sitting the child upright and applying pressure to the sides of the nose is the correct action. This position helps to reduce blood flow to the nose and applying pressure helps to stop the bleeding.
Choice D rationale
Elevating the head of the bed slightly and applying pressure to the forehead is not effective for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose to stop the bleeding. .
Correct Answer is B
Explanation
Choice A rationale
Mummy restraints, also known as swaddling, involve wrapping the infant’s body in a blanket to restrict movement. While this method can be used to calm and secure infants during certain procedures, it is not appropriate for postoperative care following cleft lip and palate repair. Mummy restraints do not prevent the infant from touching the surgical site and may cause discomfort.
Choice B rationale
Elbow restraints are the appropriate choice for an infant postoperative following cleft lip and palate repair. These restraints prevent the infant from bending their arms and touching or damaging the surgical site. Elbow restraints allow for some movement and circulation while ensuring the surgical area remains protected during the healing process. They are commonly used in pediatric postoperative care to prevent self-injury.
Choice C rationale
Jacket restraints involve securing the infant’s torso to prevent movement. While jacket restraints can be used in certain situations to ensure safety, they are not suitable for postoperative care following cleft lip and palate repair. Jacket restraints do not specifically prevent the infant from touching the surgical site and may cause unnecessary restriction and discomfort.
Choice D rationale
Wrist restraints involve securing the infant’s wrists to prevent movement. While wrist restraints can be used to prevent self-injury, they are not the best choice for postoperative care following cleft lip and palate repair. Wrist restraints may not effectively prevent the infant from reaching the surgical site and can cause discomfort and distress. .