A nurse is assessing a child with a congenital heart disease. Which symptom requires immediate intervention?
Mild cyanosis during crying or feeding.
Occasional heart palpitations.
Fatigue after physical activity.
A heart murmur audible throughout systole and diastole.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct answer. Weight gain and edema in the lower extremities can be signs of worsening heart failure in children with congenital heart defects. Fluid retention occurs due to the heart's inability to effectively pump blood, leading to fluid accumulation in the body.
B) This option is incorrect. While decreased heart rate and blood pressure within the normal range may be indicative of stable heart function, they are not specific indicators of worsening heart failure.
C) This option is incorrect. Improved appetite and increased physical activity level are positive indicators but do not specifically reflect the child's heart failure status.
D) This option is incorrect. Resolution of cyanosis and pink coloration of the lips and nail beds are positive signs of improved oxygenation and may indicate effective management of the heart defect but not the potential worsening of heart failure.
Correct Answer is D
Explanation
A) This option is incorrect. Middle-aged adults are not considered a high-risk population for congenital heart diseases. These conditions are primarily present from birth.
B) This option is incorrect. Elderly individuals are not at high risk for congenital heart diseases since these conditions are typically diagnosed at birth or during childhood.
C) This option is incorrect. While prenatal diagnosis of certain congenital heart diseases is possible through fetal echocardiography, pregnant women themselves are not at a higher risk for developing these conditions.
D) Correct answer. Neonates and infants are the highest-risk population for congenital heart diseases because these conditions are typically present from birth and may become apparent shortly after delivery or during infancy.
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