The nurse is caring for an infant who was recently diagnosed with a congenital heart defect.
Which assessment finding is most important for the nurse to report to the healthcare provider?
Audible heart murmur.
Heart rate of 162 beats/minute.
Poor oral intake and suckling effort.
Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
The Correct Answer is D
A. Many infants with congenital heart defects exhibit audible murmurs due to turbulent blood flow through abnormal openings or stenotic valves. While a murmur is a diagnostic hallmark of the condition, it is often an expected finding and does not necessarily indicate acute physiological deterioration. The nurse must document the murmur, but it is rarely the most urgent finding to report.
B. A heart rate of 162 beats/minute in an infant is slightly elevated above the typical resting range but can be triggered by crying, feeding, or baseline cardiac stress from the defect. Although tachycardia requires close monitoring to ensure the infant is not entering a state of high-output failure, it is less critical than signs of fluid overload. It represents a compensatory mechanism rather than an immediate life-threatening complication.
C. Infants with cardiac defects often experience fatigue during feeding because of the high metabolic demand and decreased cardiac output. Poor suckling effort and inadequate oral intake are common symptoms of pediatric heart failure that lead to failure to thrive over time. While this finding is significant for long-term nutritional management, it does not suggest an acute, rapid shift in stability like sudden weight changes.
D. Rapid weight gain of 1 kg within 48 hours is the most critical finding because it indicates acute fluid volume excess and potential congestive heart failure. In an infant, such a significant increase is almost certainly due to fluid retention rather than nutritional growth. This clinical sign suggests that the heart is unable to manage the systemic or pulmonary circulation effectively, necessitating immediate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Peripheral intravenous (IV) infusion is a common procedure performed on infants in a hospital setting. The selection of the IV site is critical to ensure proper placement and to prevent complications.
When starting a peripheral IV infusion on an infant, the nurse should select a site that is least restrictive to the infant. This involves selecting a site that will not restrict the infant's movement and cause discomfort. The site should be accessible, visible, and easily palpable, such as the hand, wrist, or antecubital fossa.
Assessing the dorsal surface of the feet for an IV site is not recommended as it is an area of high risk for infiltration and may restrict the infant's movement.
Instructing parents to sing or croon to the infant may provide comfort and distraction, but it is not a critical intervention when starting a peripheral IV infusion.
Applying soft restraints to all four extremities is not recommended as it may cause physical and emotional distress to the infant. It should only be used as a last resort if the infant is at high risk of self-injury or if the procedure cannot be safely performed without restraints.
Therefore, the nurse should implement the intervention of selecting a site that is least restrictive to the infant when starting a peripheral IV infusion.
Correct Answer is D
Explanation
The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today