A nurse is caring for a 10-day-old infant with a congenital heart defect. Which physical finding during nursing assessment is consistent with the patient's condition?
Periodic apneic spells of 10 seconds or less.
Fatigue during feeding.
Transient mottling of extremities.
Clubbing of fingers.
The Correct Answer is B
Choice A rationale:
Periodic apneic spells of 10 seconds or less in a 10-day-old infant could be indicative of a potential respiratory issue, but it is not directly related to congenital heart defects. Apnea spells are more commonly associated with prematurity or other respiratory conditions.
Choice B rationale:
Fatigue during feeding is consistent with a congenital heart defect. Infants with heart defects often struggle to feed due to inadequate oxygen supply and increased cardiac workload. This can lead to tiring easily during feeding.
Choice C rationale:
Transient mottling of extremities can occur in infants due to immature blood vessel regulation, especially when they are cold. While some heart conditions might contribute to poor circulation, transient mottling is not a specific finding associated with congenital heart defects.
Choice D rationale:
Clubbing of fingers typically results from chronic hypoxia and is not likely to be seen in a 10-day-old infant. It takes time for chronic hypoxia to cause clubbing, so this finding is not consistent with the patient's age or condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An hour before meals and at bedtime.
Choice A rationale:
Scheduling chest physiotherapy an hour before meals and at bedtime is optimal. This timing helps prevent aspiration during meals and aids in clearing secretions before sleep. It complements the patient's meal schedule and sleep routine.
Choice B rationale:
Every six hours around the clock could disrupt the patient's sleep and meal times. Chest physiotherapy might not align well with the patient's daily activities, potentially affecting treatment compliance and effectiveness.
Choice C rationale:
Performing chest physiotherapy upon awakening and after meals might increase the risk of aspiration during meals. Clearing airways before meals is safer, and performing it right after meals could cause discomfort.
Choice D rationale:
Evenly spaced physiotherapy when awake lacks synchronization with meal and sleep times. This approach might not optimize treatment effects and patient convenience.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring urine protein is crucial in pediatric patients with nephrotic syndrome. Nephrotic syndrome involves damage to the glomeruli in the kidneys, causing excessive protein loss in the urine, leading to hypoalbuminemia and edema.
Choice B rationale:
Urine pH is not typically a primary concern in nephrotic syndrome. This condition is more focused on proteinuria, hypoalbuminemia, and edema.
Choice C rationale:
Leukocytes in the urine may indicate a urinary tract infection (UTI), but this is not a hallmark feature of nephrotic syndrome. UTIs are not the primary concern in this scenario.
Choice D rationale:
Ketones in the urine could indicate diabetic ketoacidosis or starvation, which are not directly related to nephrotic syndrome. Ketones are not a key indicator in nephrotic syndrome assessment.
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