A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.)

Increased urinary output

Nasal flaring

Peripheral edema

Bradycardia

Answer and Explanation

Correct Answer : B,C

Choice A reason: Increased urinary output is not typically associated with heart failure. In fact, reduced urinary output may be expected due to decreased kidney perfusion.

Choice B reason: Nasal flaring is a sign of respiratory distress and can be expected in infants with heart failure as they struggle to maintain oxygenation.

Choice C reason: Peripheral edema is a common finding in heart failure due to fluid retention and poor circulation.

Choice D reason: Bradycardia is not a typical sign of heart failure in infants; tachycardia is more common. However, bradycardia can occur in advanced stages due to poor cardiac output.

Choice E reason: Cool extremities are indicative of poor perfusion, which is a consequence of decreased cardiac output in heart failure.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Waiting 30 seconds between puffs allows the medication to settle and ensures the second puff is as effective as the first.

Choice B reason: Shaking the device before use helps to mix the medication properly, ensuring a consistent dose with each inhalation.

Choice C reason: Exhaling quickly after inhalation is not recommended; instead, the patient should hold their breath for a few seconds to allow the medication to reach deep into the lungs.

Choice D reason: Rinsing the mouth and expectorating after administration prevents oral thrush, a common side effect of inhaled corticosteroids.

Choice E reason: Inhaling slowly ensures that the medication is delivered deeply into the lungs for maximum efficacy.

A. Place the child in the Fowler's position. B. Ensure proper placement of the sensor probe. C. Increase the oxygen flow rate. D. Encourage the child to take deep breaths.

Correct Answer is B

Explanation

Choice A reason: While the Fowler's position can aid in breathing, it is not the first action to take if the oxygen saturation monitor is reading low.

Choice B reason: Ensuring the proper placement of the sensor probe is the first step, as incorrect placement can lead to inaccurate readings.

Choice C reason: Increasing the oxygen flow rate should only be considered after confirming the accuracy of the oxygen saturation reading.

Choice D reason: Encouraging deep breaths may be helpful, but it is not the first action to take. The priority is to ensure the oxygen saturation reading is accurate.

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A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.)

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