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: Giving the toddler planned, frequent, and nutritious snacks is a good way to meet her nutritional needs and respect her natural appetite. Toddlers have small stomachs and high energy levels, so they may not eat much at one sitting. They may also be easily distracted or bored by sitting at the table for too long. Snacks can provide additional calories and nutrients that they may miss at mealtimes. However, the snacks should be healthy, such as fruits, vegetables, cheese, yogurt, or whole-grain crackers. They should also be offered at regular times, not on demand, and not too close to mealtimes.

Choice B reason: Explaining to the toddler in a firm manner what is expected of her is not a helpful or realistic strategy to improve her eating habits. Toddlers are naturally curious and independent, and they may not understand or follow the rules that adults set for them. They may also resist or rebel against pressure or coercion to eat. Instead of lecturing or scolding the toddler, the parents should model good eating behaviors, praise her when she tries new foods, and avoid power struggles or arguments over food.

Choice C reason: Avoiding snacks so the toddler is hungry at mealtimes is not a wise or healthy suggestion. This may backfire and cause the toddler to become more fussy, irritable, or tired. It may also lead to overeating, bingeing, or unhealthy food choices later on. Hunger is not the only factor that influences a toddler's appetite. Other factors include mood, activity level, environment, and preferences. The parents should not use hunger as a tool to manipulate the toddler's eating, but rather respect her hunger and fullness cues.

Choice D reason: Offering rewards for eating at mealtimes is not a beneficial or sustainable method to encourage the toddler to eat. Rewards may be material, such as toys or stickers, or edible, such as sweets or desserts. Rewards may work temporarily, but they may also have negative consequences. They may undermine the toddler's intrinsic motivation to eat, or make her associate eating with external rewards rather than internal satisfaction. They may also create an imbalance in the value of different foods, or make the toddler feel guilty or deprived. The parents should not bribe or bargain with the toddler to eat, but rather make eating a pleasant and enjoyable experience.

Choice A reason: Mechanical ventilation does not necessarily increase the fluid requirements of a child. Mechanical ventilation is a method of providing artificial breathing support to a child who has respiratory failure or insufficiency. Mechanical ventilation may affect the fluid balance of a child by altering the insensible losses, the renal function, or the hemodynamics. However, the net effect may vary depending on the type, mode, and settings of the ventilator, as well as the underlying condition of the child. Therefore, the fluid requirements of a child on mechanical ventilation should be individualized and monitored closely¹.

Choice B reason: Increased intracranial pressure (ICP) does not increase the fluid requirements of a child. Increased ICP is a condition in which the pressure inside the skull is higher than normal, due to various causes such as head injury, brain tumor, infection, or hydrocephalus. Increased ICP may affect the fluid balance of a child by impairing the cerebral blood flow, the cerebrospinal fluid drainage, or the hypothalamic-pituitary axis. However, the net effect may vary depending on the severity, duration, and cause of the increased ICP, as well as the presence of other complications such as cerebral edema or diabetes insipidus. Therefore, the fluid requirements of a child with increased ICP should be individualized and monitored closely².

Choice C reason: Congestive heart failure does not increase the fluid requirements of a child. Congestive heart failure is a condition in which the heart is unable to pump enough blood to meet the body's needs, due to various causes such as congenital heart defects, cardiomyopathy, or infection. Congestive heart failure may affect the fluid balance of a child by causing fluid retention, edema, or pulmonary congestion. However, the net effect may vary depending on the type, severity, and stage of the heart failure, as well as the presence of other complications such as renal failure or liver failure. Therefore, the fluid requirements of a child with congestive heart failure should be individualized and monitored closely³.

Choice D reason: Fever increases the fluid requirements of a child. Fever is a condition in which the body temperature is higher than normal, due to various causes such as infection, inflammation, or immunization. Fever increases the fluid requirements of a child by increasing the metabolic rate, the insensible losses, and the urine output. The amount of fluid loss due to fever depends on the degree and duration of the fever, as well as the ambient temperature and humidity. A general rule of thumb is that for every degree Celsius increase in body temperature, the fluid requirements increase by 10%⁴. Therefore, the fluid requirements of a child with fever should be adjusted and monitored closely.