Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)

Tachypnea

Wheezes or rales

Bounding pulses

Edematous

Difficulty feeding

Increased comfort laying down

Answer and Explanation

Correct Answer : A,B,D,E

A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.

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Correct Answer is C

Explanation

A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.

A. Assess motor function in lower extremities B. Maintain skin integrity C. Monitor intake and output D. Monitor head circumference

Correct Answer is D

Explanation

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

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Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

Correct Answer is C

Explanation

What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Correct Answer is D

Explanation

A new student nurse is learning about Mental health. Which of the following should be stated as representation of a nursing intervention at the tertiary level of prevention in mental health?

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