A nurse is assessing an infant who has congestive heart failure. Which of the following findings should the nurse expect?
Increased urine output
Bradycardia
Increased blood pressure
Tachypnea
The Correct Answer is D
A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["89"]
Explanation
Determine the infant's weight in kg:13 lb ÷ 2.2 = 5.91 kg
Calculate the total daily dose:30 mg/kg/day × 5.91 kg = 177.3 mg/day
Divide the total daily dose by 2 (since the medication is given every 12 hours):177.3 mg ÷ 2 = 88.65 mg per dose
Round to the nearest whole number:89 mg per dose
Correct Answer is A
Explanation
A. "Apply a light blanket if the child begins to shiver." Shivering can increase body temperature, so a light blanket can provide comfort while preventing excessive heat retention. Over-bundling should be avoided.
B. "Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice." Encouraging fluid intake is important, but waking a sleeping child is unnecessary unless there are concerns about dehydration. Instead, fluids should be offered frequently while the child is awake.
C. "Take the child's temperature every 10 min after administering acetaminophen." Checking the temperature this frequently is not necessary and could cause unnecessary stress for the child. Acetaminophen typically takes 30–60 minutes to take effect, so temperature checks should be spaced appropriately.
D. "Place ice packs on the child's armpits and groin." Using ice packs can cause shivering, which increases body temperature. Instead, cooling measures like a lukewarm sponge bath or removing excess clothing are preferred.
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