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 C
Infants with congenital heart defects may have difficulty with feeding due to increased effort required to breathe and feed at the same time. This can lead to poor weight gain and dehydration. Thus, it is important for the nurse to report any signs of poor feeding or oral intake to the healthcare provider. While audible heart murmur (choice A) and a high heart rate (choice B) are expected findings in infants with congenital heart defects, they do not necessarily indicate a need for immediate intervention. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours (choice D) may actually be a positive finding in an infant with a congenital heart defect, but it is not as important to report as poor oral intake and suckling effort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should include rice in the list of allowed foods for a child who is newly diagnosed with celiac disease. Rice is a gluten-free grain and is safe for individuals with celiac disease to consume. Rye, oats, and barley all contain gluten and should be avoided by individuals with celiac disease. However, some individuals with celiac disease may be able to tolerate oats that are certified gluten-free and not contaminated with other gluten-containing grains.
Correct Answer is B
Explanation
Information about the child's reactions to any previous hospitalizations would be particularly helpful in planning care for this six-year-old girl who is being admited for repair of an umbilical hernia. This information can help the nurse anticipate and address any fears or concerns the child may have about the hospitalization and procedure.
A list of achievement timeline for developmental milestones is not particularly relevant in this situation.
A history of rubella, rubeola, or chicken pox is not particularly relevant in this situation.
Information about the mother's use of alcohol, drugs, or cigaretes during pregnancy is not particularly relevant in this situation.
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