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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

A. Inspect the posterior oropharynx. B. Touch the tonsillar pillars to stimulate the gag reﬂex. C. Ask the child to speak to evaluate change in voice tone. D. Assess for teeth clenching or grinding.

Correct Answer is A

Explanation

The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.

Touching the tonsillar pillars to stimulate the gag reﬂex or asking the child to speak would not provide information about the presence of bleeding.

Assessing for teeth clenching or grinding is not related to this particular observation.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Correct Answer is A

Explanation

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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?