An infant is brought to the emergency department with suspected coarctation of the aorta. Which clinical symptoms would the nurse expect to find?
Cyanosis of the lips and tongue
Weak or absent femoral pulses
Bounding pulses in the upper extremities
High blood pressure in the lower extremities
Poor feeding and irritability
Correct Answer : B,C,E
A. Cyanosis of the lips and tongue is not a typical finding in coarctation of the aorta; rather, it is more associated with cyanotic congenital heart defects.
B. Weak or absent femoral pulses are expected due to reduced blood flow to the lower body, as the coarctation typically occurs distal to the left subclavian artery.
C. Bounding pulses in the upper extremities are common because the blood flow to the upper body is increased, leading to stronger pulses.
D. High blood pressure in the lower extremities is not typical; instead, there is often lower blood pressure in the lower body due to the obstruction.
E. Poor feeding and irritability are common symptoms in infants with heart conditions, as they may be in distress or not getting enough blood flow to meet their metabolic needs.
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Correct Answer is B
Explanation
A. This option is incorrect as it does not describe the expected blood pressure difference in coarctation of the aorta.
B. Coarctation of the aorta typically presents with higher blood pressure in the upper body (arms) and lower blood pressure in the lower body (legs) due to the obstruction of blood flow distal to the aortic arch.
C. This option is incorrect because while coarctation can lead to decreased perfusion in the lower extremities, it does not typically result in decreased blood pressure in both the arms and legs simultaneously.
D. While increased blood pressure may occur in the arms, the legs would not typically show increased blood pressure in cases of coarctation.
Correct Answer is D
Explanation
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.