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 D

Explanation

A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.

A. Limit alcohol and caffeine intake B. Decreasing the intake of dairy products C. Performing regular weight-bearing exercises D. Taking vitamin E and B complex vitamin supplements

Correct Answer is A

Explanation

A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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

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