fect (head and upper extremities, right greater than left) and decreased blood pressure distal to the obstruction (torso and lower extremities) in coarctation of the aorta. Clubbing of the fingers occurs with chronic cyanosis.p 65640) Which behavior will alert a nurse to monitor an infant with tetralogy of Fallot for a "tet" spell?A.CryingT.SittingU.SleepingV.SquattingW.RationaleHypercyanotic spells or "tet" spells may occur during crying or after feed-ing. Squatting can help with cyanosis. Sitting and sleeping do not cause "tet" spells.p 66141) To help determine the diagnosis of systemic hypertension in a child, which action should the nurse take?A.Take the blood pressure lying and standing.X.Take the blood pressure on three separate occasions.Y.Compare blood pressure readings with oxygen saturation levels.Z.Compare the blood pressure of the upper extremities to that of the lower extremities.Rationale
The examination should include an accurate blood pressure measurement on three separate occasions using an appropriately sized cuff. Comparing the blood pressure readings with oxygen saturation levels is not diagnostic for systemic hypertension. Taking the blood pressure lying and standing helps determine orthostatic hypotension. Comparing the blood pressure of the upper extremities to that of the lower extremities is helpful in coarctationof the aorta.p 667-66842) An infant has left-sided heart failure. Which finding will the nurse typi-cally observe on assessment?A.CoughingAA.WheezingBB.Failure to thriveCC.Peripheral edemaRationaleLeft-sided heart failure in infants is manifested as poor feeding and suck-ing, often leading to failure to thrive. Wheezing, coughing, and rales are rare in childhood congestive heart failure. Systemic venous congestion is rare in childhood; peripheral edema and weight gain suggest renal disease or nutritional disease more than heart failure.p 66543) Upon assessment of an infant, the nurse finds no cyanosis even thoughthe infant has a congenital heart condition. Which infant did the nurse as-sess?A.An infant with tetralogy of FallotDD.An infant with truncus arteriosusEE.An infant with patent ductus arteriosusFF.An infant with transposition of the great arteriesRationalePatent ductus arteriosus is an acyanotic disorder. Tetralogy of Fallot, trun-cus arteriosus, and transposition of the great arteries are cyanotic disor-ders.p 656
44) Which assessment finding would the nurse expect to observe in an in-fant with left ventricular heart failure?A.CoughingGG.Weight gainHH.Poor suckingII.Peripheral edemaRationalePoor feeding or poor sucking is often found in left ventricular heart failure and leads to failure to thrive. Coughing is rare in children with left ventricu-lar heart failure. Peripheral edema and weight gain more rapid than the baseline rate expected for the infant's age usually indicate renal or nutri-tional problems, not cardiac dysfunction.
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- Fall '19
- Congenital heart defect, Tetralogy of Fallot, Atrial septal defect, Ductus Arteriosus