A four-month-old infant is hospitalized for repair of a ventricular septal defect. The infant's admitting diagnosis is moderate congestive heart failure. If the infant's CHF worsens, the nurse may implement which of the following interventions, assuming an order was written?

Choice A reason: Abdominal pain that is most intense at McBurney point is a classic sign of acute appendicitis. McBurney point is located about two-thirds of the way from the navel to the right hip bone. It is the site of the base of the appendix, where the inflammation is most severe. The pain usually starts around the navel and then shifts to the lower right abdomen. The pain may worsen with movement, coughing, or pressure.

Choice B reason: Rebound tenderness is a symptom of peritonitis, which is a complication of acute appendicitis. Peritonitis is an inflammation of the lining of the abdominal cavity, which can occur if the appendix ruptures and spills its contents. Rebound tenderness is a sharp pain that occurs when the abdomen is quickly released after being gently pressed. It indicates irritation of the peritoneum, the membrane that covers the abdominal organs.

Choice C reason: Abdominal pain that is relieved by eating is not a typical feature of acute appendicitis. In fact, appendicitis may cause loss of appetite, nausea, and vomiting. Eating may worsen the pain by stimulating the digestive tract and increasing the pressure on the appendix.

Choice D reason: Bright red or dark red rectal bleeding is not a common manifestation of acute appendicitis. It may indicate other conditions, such as hemorrhoids, anal fissures, diverticulitis, ulcerative colitis, or colon cancer. Rectal bleeding may occur in some cases of appendicitis if the inflammation affects the cecum, the first part of the colon, but it is usually not bright or dark red.

Choice A reason: This is not a correct statement, as bradycardia, bounding pulses, and cyanosis are not typical signs and symptoms of moderate congestive heart failure. Bradycardia may indicate a heart block or a vagal response, bounding pulses may indicate a patent ductus arteriosus or aortic regurgitation, and cyanosis may indicate a severe right-to-left shunt or a pulmonary embolism¹.

Choice B reason: This is not a correct statement, as overdiuresis, increased appetite, and increased thirst are not typical signs and symptoms of moderate congestive heart failure. Overdiuresis may indicate a renal dysfunction or a diuretic overdose, increased appetite may indicate a normal growth spurt or a metabolic disorder, and increased thirst may indicate dehydration or diabetes¹.

Choice C reason: This is not a correct statement, as wheezing, pallor, and capillary refill time < 2 seconds are not typical signs and symptoms of moderate congestive heart failure. Wheezing may indicate a bronchospasm or an asthma attack, pallor may indicate anemia or shock, and capillary refill time < 2 seconds may indicate a normal or increased peripheral perfusion¹.

Choice D reason: This is the correct statement, as tachypnea, cough, and tachycardia are typical signs and symptoms of moderate congestive heart failure. Tachypnea may indicate a respiratory distress or a pulmonary edema, cough may indicate a fluid accumulation or an infection in the lungs, and tachycardia may indicate a compensatory mechanism or a cardiac arrhythmia¹².