A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.)

Increased urinary output

Nasal flaring

Peripheral edema

Bradycardia

Answer and Explanation

Correct Answer : B,C

Choice A reason: Increased urinary output is not typically associated with heart failure. In fact, reduced urinary output may be expected due to decreased kidney perfusion.

Choice B reason: Nasal flaring is a sign of respiratory distress and can be expected in infants with heart failure as they struggle to maintain oxygenation.

Choice C reason: Peripheral edema is a common finding in heart failure due to fluid retention and poor circulation.

Choice D reason: Bradycardia is not a typical sign of heart failure in infants; tachycardia is more common. However, bradycardia can occur in advanced stages due to poor cardiac output.

Choice E reason: Cool extremities are indicative of poor perfusion, which is a consequence of decreased cardiac output in heart failure.

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Correct Answer is C

Explanation

Choice A reason: The FACES scale is not typically used for infants as they cannot verbally express or select a face that correlates with their pain level.

Choice B reason: The Oucher scale requires a child to point to a face that shows how much pain they are feeling, which is not suitable for infants who cannot communicate their pain verbally.

Choice C reason: The FLACC scale is appropriate for infants as it assesses pain based on five categories of behavior: Facial expression, Leg movement, Activity, Cry, and Consolability.

Choice D reason: The Non-communicating children's pain checklist is designed for children with cognitive impairments and is not the best choice for assessing pain in infants.

A. Administer an antidiuretic. B. Encourage frequent voiding. C. Evaluate the child's self-esteem. D. Restrict fluids.

Correct Answer is B

Explanation

Choice A reason: Administering an antidiuretic would be counterproductive in the treatment of a UTI as it would decrease urine output, potentially allowing bacteria to remain in the urinary tract.

Choice B reason: Encouraging frequent voiding helps to flush out bacteria from the urinary tract, which is beneficial in the management of a UTI.

Choice C reason: While evaluating a child's self-esteem is important, it is not directly related to the care of a child with a UTI.

Choice D reason: Restricting fluids is not advisable for a UTI as it would reduce urine flow and hinder the flushing out of bacteria.

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A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.)

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