The nurse is collecting data on a 2 month-old-child with left-sided congestive heart failure. Which clinical manifestation would support this diagnosis of left-sided congestive heart failure?

Edema in the lower extremities

Ascites

Shortness of breath

Hepatomegaly

Answer and Explanation

The Correct Answer is C

A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.

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Correct Answer is ["90"]

Explanation

The nurse should withhold the dose if the infant's apical heart rate is less than 90 beats per minute.

Digoxin is a medication that can slow the heart rate. If an infant's heart rate is already too slow, administering digoxin can increase the risk of bradycardia, a serious heart rhythm disturbance.

It's important to monitor the apical heart rate for a full minute before administering digoxin to an infant and to withhold the dose if the heart rate is below the specified threshold.

A. "Has the child had any difficulty swallowing food?" B. "Does the child play with an imaginary friend?" C. "Does the child respond when called by name? D. "Was the child recently treated for pneumonia?

Correct Answer is A

Explanation

A. "Has the child had any difficulty swallowing food?"
Explanation:
One potential long-term effect of cleft palate repair is difficulty with swallowing or feeding. Cleft palate repair aims to improve the child's ability to eat and speak, but some children may continue to face challenges with swallowing or have a history of difficulty feeding.
B. "Does the child play with an imaginary friend?"
Explanation: Imaginary play is not specifically related to the long-term effects of cleft palate repair. This question does not provide information about the physical outcomes of the surgical repair.
C. "Does the child respond when called by name?"
Explanation: Responsiveness to being called by name is a general developmental question but does not specifically address the long-term effects of cleft palate repair.
D. "Was the child recently treated for pneumonia?"
Explanation: While respiratory issues can be associated with cleft palate, this question focuses on a recent event rather than the long-term effects. Asking about difficulty swallowing or feeding may provide more information about ongoing concerns related to the cleft palate repair.

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The nurse is collecting data on a 2 month-old-child with left-sided congestive heart failure. Which clinical manifestation would support this diagnosis of left-sided congestive heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

Correct Answer is ["90"]

Explanation

A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question would the nurse ask the parent?

Correct Answer is A

Explanation

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