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 ["C","D","E"]
Explanation
A. Pertussis, or whooping cough, primarily affects the respiratory tract, particularly the trachea and bronchi, not just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making this statement incorrect as the infection is bacterial, not viral.
C. The toxins released by Bordetella pertussis damage the cilia of epithelial cells in the respiratory tract, leading to difficulty in clearing secretions.
D. The inflammation of the lungs and airways is a characteristic response to the infection, contributing to the symptoms of coughing and difficulty breathing.
E. The production of thick, mucus secretions is a hallmark of pertussis, which makes it challenging for the child to expel them, leading to severe coughing fits.
Correct Answer is C
Explanation
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.