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A nurse is assessing a child with a congenital heart disease. Which symptom requires immediate intervention?

A.

Mild cyanosis during crying or feeding.

B.

Occasional heart palpitations.

C.

Fatigue after physical activity.

D.

A heart murmur audible throughout systole and diastole.

Answer and Explanation

The Correct Answer is A

A) The answer is A. Mild cyanosis during crying or feeding can indicate inadequate oxygenation and increased workload on the heart. This symptom requires immediate intervention to ensure proper oxygen supply to vital organs.

B) Incorrect. Occasional heart palpitations may not be a severe concern and may not require immediate intervention. However, the healthcare provider should still be notified for further evaluation.

C) Incorrect. Fatigue after physical activity is common in clients with congenital heart diseases due to compromised cardiac function. Although it needs attention, it does not require immediate intervention.

D) Incorrect. A heart murmur audible throughout systole and diastole can indicate structural heart abnormalities. While it requires medical follow-up, it may not need immediate intervention unless accompanied by other concerning symptoms.


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Related Questions

Correct Answer is ["A"]

Explanation

A. This statement indicates a misunderstanding. Congenital heart diseases are present at birth and are not caused by infections, lifestyle factors, or events during childhood. This shows the client needs further education.

B. This statement is accurate because congenital heart diseases are structural or functional heart problems present from birth.

C. This statement is correct. Some congenital heart defects can be detected before birth using fetal echocardiography.

D. This statement is correct. Management of congenital heart diseases can include medications, surgical interventions, or other medical treatments depending on the condition.

Correct Answer is B

Explanation

A) Incorrect. While solid foods are introduced around six months of age, the nurse should consider the specific condition of the infant's congenital heart disease before giving feeding recommendations.

B) The answer is B. Infants with congenital heart diseases may tire easily during feeding due to the increased effort required for sucking and swallowing. Feeding small, frequent meals can help prevent fatigue and ensure adequate nutrition.

C) Incorrect. Breastfeeding is generally encouraged, even for infants with congenital heart diseases. However, the nurse should consider any specific feeding challenges the infant may have due to their heart condition and provide appropriate support and guidance.

D) Incorrect. Limiting fluid intake may not be necessary unless specifically advised by the healthcare provider. Infants need sufficient hydration, and fluid intake should be managed based on the infant's overall health and condition.

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