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 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 ["1.8"]
Explanation
The nurse should administer 1.8 mL of diazepam.
To calculate the volume of diazepam to be administered, you would first calculate the total dose of diazepam for this child by multiplying the child's weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg x 0.3 mg/kg = 9 mg). Next, you would divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg / 5 mg/mL = 1.8 mL).
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