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
Choice A rationale:
Refeeding any thrust out food to the baby is incorrect as it increases the risk of choking and aspiration. Parents should discard food that the baby has pushed out to prevent potential harm.
Choice B rationale:
Avoiding the use of skin lubricants on the baby is appropriate as these products might irritate the baby's sensitive skin.
Choice C rationale:
Suctioning the baby's nose before feedings is important to ensure proper breathing and effective feeding, especially in infants with Down Syndrome who may have nasal congestion.
Choice D rationale:
Using minimal soap when bathing the baby is appropriate to prevent skin irritation. Babies have delicate skin, and excessive soap can lead to dryness and discomfort.
Correct Answer is D
Explanation
Choice A rationale:
Maintaining supplemental oxygen is not directly relevant to the management of hemarthrosis in a patient with hemophilia. Hemarthrosis is bleeding into a joint due to impaired clotting factors in hemophilia, and oxygen supplementation is not a primary intervention.
Choice B rationale:
Elevating the head of the bed 45 degrees is not the most appropriate action for hemarthrosis. Elevation would not address the joint bleeding, and it could potentially cause discomfort to the patient.
Choice C rationale:
Providing passive range-of-motion exercises to all extremities is contraindicated in this scenario. Active or passive range-of-motion exercises could exacerbate bleeding and further damage the affected joint in a patient with hemarthrosis.
Choice D rationale:
Immobilizing the affected joint is the correct nursing action. Immobilization helps to prevent further bleeding and joint damage. By limiting movement, the risk of exacerbating the bleeding is minimized, promoting healing and reducing pain.
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