A nurse is caring for a 10-day-old infant with a congenital heart defect. Which physical finding during nursing assessment is consistent with the patient's condition?
Periodic apneic spells of 10 seconds or less.
Fatigue during feeding.
Transient mottling of extremities.
Clubbing of fingers.
The Correct Answer is B
Choice A rationale:
Periodic apneic spells of 10 seconds or less in a 10-day-old infant could be indicative of a potential respiratory issue, but it is not directly related to congenital heart defects. Apnea spells are more commonly associated with prematurity or other respiratory conditions.
Choice B rationale:
Fatigue during feeding is consistent with a congenital heart defect. Infants with heart defects often struggle to feed due to inadequate oxygen supply and increased cardiac workload. This can lead to tiring easily during feeding.
Choice C rationale:
Transient mottling of extremities can occur in infants due to immature blood vessel regulation, especially when they are cold. While some heart conditions might contribute to poor circulation, transient mottling is not a specific finding associated with congenital heart defects.
Choice D rationale:
Clubbing of fingers typically results from chronic hypoxia and is not likely to be seen in a 10-day-old infant. It takes time for chronic hypoxia to cause clubbing, so this finding is not consistent with the patient's age or condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I will take the enzymes with all my meals and snacks.”.
Choice A rationale:
Taking pancreatic enzymes with all meals and snacks is the correct approach. Pancreatic enzymes are essential for aiding digestion and should be taken whenever food is consumed to ensure proper nutrient absorption.
Choice B rationale:
Taking enzymes only with meals is insufficient. Snacks also require enzyme supplementation for effective digestion.
Choice C rationale:
Waiting for complications before taking enzymes is incorrect. Enzymes are necessary for every meal and snack to prevent malabsorption and digestive issues.
Choice D rationale:
Taking enzymes at night before bed is not recommended. Enzymes are needed when food is present in the stomach, which typically occurs during meals and snacks, not before bedtime.
Correct Answer is D
Explanation
Choice A rationale:
Instructing the mother in palpation of bladder distention might not effectively address the issue of incomplete bladder emptying. Clean intermittent catheterization is a more appropriate technique to ensure complete emptying.
Choice B rationale:
Informing the mother that life-long antibiotic administration will be necessary is not the primary approach. Antibiotics may be required in specific situations, but addressing incomplete emptying is the key focus.
Choice C rationale:
Preparing the mother for the need for urinary diversion surgery is premature. Clean intermittent catheterization is a conservative measure that should be attempted before considering surgical options.
Choice D rationale:
Instructing the mother in the technique of clean intermittent catheterization helps manage the neurogenic bladder's incomplete emptying. This technique reduces the risk of urinary tract infections and promotes bladder health.
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