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    Hesi compass B exit proctored exam

    The nurse is assessing an infant on admission to the newborn nursery and finds that both brachial pulses are bounding, but bilateral femoral pulses are only slightly palpable. Which assessment should the nurse implement next?

    Explanation & Rationale

    A. Obtaining blood pressures in all extremities is correct because unequal pulses and weak femoral pulses may indicate coarctation of the aorta or other congenital heart defects, which typically cause higher blood pressure in the upper extremities compared to the lower. B. Assessing heart sounds for a murmur is important but follows blood pressure measurement to help confirm diagnosis. C. Evaluating the legs for edema is less specific and less urgent than determining blood pressure differences. D. Listening for lung crackles is important if heart failure is suspected, but initial focus should be on confirming pulse and pressure discrepancies.

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