A 3-year-old child with congestive heart failure resulting from an underlying congenital heart defect, is prescribed digoxin and furosemide. Which of the following assessment findings are MOST concerning?
A blood pressure of 100/56 and a small weight gain
A heart rate of 150 beats/minute with crying
An apical pulse of 70 beats/minute and vomiting
An hourly urine output of 45mL/hour
The Correct Answer is C
A. A blood pressure of 100/56 and a small weight gain may indicate fluid retention, but they are not immediately life-threatening.
B. A heart rate of 150 beats/minute with crying can be normal for a child of this age, especially during emotional distress.
C. An apical pulse of 70 beats/minute and vomiting are concerning because they may indicate digoxin toxicity. A low heart rate (bradycardia) in a child on digoxin requires immediate attention.
D. An hourly urine output of 45 mL/hour is adequate and not concerning in this context.
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Related Questions
Correct Answer is B
Explanation
A. While providing assistance with activities of daily living is important, ensuring the child's environment is safe is a higher priority to prevent injuries.
B. Modifying the home for safety is the priority because children with hemiplegic cerebral palsy have motor impairments that increase their risk for accidents and injuries. A safe environment is essential for the child’s well-being.
C. Providing respite services for the parents is beneficial for the family’s overall stress management, but it is not as immediate a concern as ensuring the child’s safety.
D. Improving communication skills is important for the child's overall development, but ensuring a safe living environment takes precedence to prevent potential harm.
Correct Answer is D
Explanation
A. Prone and in full Trendelenburg position is not appropriate as it could increase intracranial pressure and compromise breathing.
B. Supine with head slightly elevated is not suitable because it can put pressure on the myelomeningocele sac.
C. Side-lying with head slightly elevated is also not ideal as it can lead to pressure on the sac.
D. Prone with hips flexed and legs abducted is the best position to avoid pressure on the myelomeningocele sac, prevent trauma, and reduce the risk of infection before surgical repair.
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