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.
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Correct Answer is C
Explanation
Choice A rationale:
Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.
Choice B rationale:
Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.
Choice C rationale:
Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.
Choice D rationale:
Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.
Correct Answer is C
Explanation
Reviewing the patient's complete blood count.
Choice A rationale:
Measuring height is not a priority when administering zidovudine.
Choice B rationale:
Monitoring weight gain is important but not the first priority.
Choice C rationale:
Reviewing the complete blood count is crucial before administering zidovudine, as this medication can cause bone marrow suppression. Checking for changes in white blood cell counts, hemoglobin, and platelet levels is essential to ensure the patient can tolerate the medication without severe adverse effects.
Choice D rationale:
Reviewing the patient's chemistry profile is relevant, but assessing blood counts is more critical due to zidovudine's potential impact on bone marrow function.
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