A nurse is caring for a child who is postoperative following surgical correction of Tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?

Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.

Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.

Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.

Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.

Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.

Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.

Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.

Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.