Maternal Child NCLEX Review Questions With Complete Solutions!!

A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having respiratory distress? A. Flaring nostrils B. Sporadic crying C. Ineffective cough D. Decreased pulse rate - ANSWER-Answer: A Rationale: In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative of infant distress but are not classic signs of respiratory distress. A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is indicative of a defect that: A. typically results in cyanosis B. may result in congestive heart failure C. also causes pulmonary stenosis D. normally does not close after birth - ANSWER-Answer: B Rationale: Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there may not be any signs of the disorder.