A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
heart rate 162/min
negative doll's eye reflex.
Sunken anterior fontanel
potassium 5.1MEq/L
The Correct Answer is C
The correct answer is choice c. Sunken anterior fontanel.
Choice A rationale:
A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.
Choice B rationale:
A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.
Choice C rationale:
A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.
Choice D rationale:
A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.
Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Providing a pacifier coated with an oral sucrose prior to injections can help reduce the infant’s pain response. The sweetness of the sucrose can distract the infant and provide some comfort.
Choice B rationale
Injecting the immunizations into the deltoid muscle is not recommended for infants. The deltoid muscle is not usually used until children are older and have more muscle mass.
Choice C rationale
Using a 20-gauge needle for injections is not typically recommended for infants. Smaller gauge needles are usually used to minimize discomfort.
Choice D rationale
Applying a eutectic mixture of local anesthetics cream immediately before the injections can help numb the skin and reduce pain. This can make the injection process less distressing for the infant.
Correct Answer is A
Explanation
Choice A rationale
Tachypnea, or rapid breathing, is a common clinical manifestation of heart failure in children. This occurs because the heart is unable to pump enough blood to meet the body’s needs, causing fluid to back up into the
lungs and leading to shortness of breath and rapid breathing.
Choice B rationale
Contrary to increased appetite, children with heart failure often experience a decrease in appetite or difficulty feeding. This is due to increased energy expenditure and early satiety caused by abdominal distension from hepatomegaly or ascites.
Choice C rationale
Tremors are not typically associated with heart failure. They could be a sign of other neurological conditions, side effects of certain medications, or anxiety.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is not typically a symptom of heart failure. In fact, tachycardia, or a faster than normal heart rate, is more commonly seen in heart failure as the heart tries to compensate for its reduced ability to pump blood.
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