A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

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Question 1 of 5

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

Correct Answer: C

Rationale: A ventricular septal defect (VSD) is a congenital heart defect characterized by a hole in the septum that separates the heart's two lower chambers (ventricles). When assessing a child with an unrepaired VSD, the nurse would expect to hear a murmur. The murmur is typically described as a harsh, holosystolic (pansystolic) murmur, best heard at the left lower sternal border. This murmur occurs due to the turbulent blood flow across the defect during systole. It is important for the nurse to recognize this characteristic murmur associated with a VSD to facilitate appropriate management and follow-up care for the child.

Question 2 of 5

The nurse would monitor the client for which of the following?

Correct Answer: A

Rationale: Trousseau's sign is a clinical sign characterized by carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. It is indicative of hypocalcemia, specifically low calcium levels in the blood. Therefore, the nurse would monitor the client for Trousseau's sign to assess for potential hypocalcemia. This could prompt the healthcare provider to order further diagnostic tests or interventions to address the underlying calcium imbalance. Options B, C, and D do not directly relate to monitoring for Trousseau's sign.

Question 3 of 5

The MOST appropriate age of a child who helps to undress; puts 3 words together (subject, verb, object); and handles spoon well is

Correct Answer: C

Rationale: These milestones are typically achieved around 24 months.

Question 4 of 5

What does the surgical closure of the ductus arteriosus do?

Correct Answer: A

Rationale: The ductus arteriosus is a fetal blood vessel that allows blood to bypass the lungs while in utero. After birth, the ductus arteriosus should close to redirect blood flow through the lungs for oxygenation. Surgical closure of the ductus arteriosus is performed to prevent the shunting of unoxygenated blood from the pulmonary artery to the aorta, therefore stopping the loss of unoxygenated blood to the systemic circulation. This helps to ensure that oxygenated blood is properly circulated to the body tissues and organs.

Question 5 of 5

Which is true of a Wilms tumor? (Select all that apply.)

Correct Answer: C

Rationale: Wilms tumor typically occurs in children aged 2-5 years and may be associated with congenital anomalies. It is not the same as neuroblastoma, and its prognosis is generally good with treatment.

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