A nurse is caring for an infant suspected of having a congenital heart disease. Which assessment finding is most indicative of this condition?
The infant's skin is pale and cool to the touch.
The infant's respiratory rate is within the normal range.
The infant's fontanelle is closed and firm.
The infant's weight gain follows the growth chart percentile for age.
The Correct Answer is A
A) The answer is A. The pallor and coolness of the skin may indicate poor cardiac output and impaired circulation commonly seen in congenital heart diseases. These signs are suggestive of reduced oxygen delivery to peripheral tissues.
B) Incorrect. The respiratory rate being within the normal range does not specifically point to a congenital heart disease. Other signs and symptoms should be assessed to confirm the diagnosis.
C) Incorrect. The closure and firmness of the fontanelle are related to the status of the infant's skull bones and do not directly indicate congenital heart disease.
D) Incorrect. Weight gain following the growth chart percentile for age is not directly associated with congenital heart diseases. There are more specific clinical indicators to consider in the assessment of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) The answer is A. Monitoring urine output closely is essential postoperatively to assess kidney perfusion and fluid balance, as infants are at risk of fluid shifts after cardiac surgery.
B) Incorrect. While administering prescribed analgesics is important for postoperative pain management, it is not the priority intervention among the options provided.
C) Incorrect. Encouraging deep breathing and coughing exercises is important to prevent respiratory complications, but it is not the priority intervention immediately after cardiac surgery.
D) Incorrect. Elevating the head of the bed can help with respiratory effort, but it is not the priority intervention. Monitoring urine output and fluid balance is more critical in the early postoperative period.
Correct Answer is A
Explanation
C) Incorrect. Dairy products rich in calcium are not contraindicated with enalapril use. Calcium and ACE inhibitors do not have direct interactions.
D) Incorrect. Foods high in vitamin B12 are not contraindicated with enalapril use. There is no specific dietary restriction regarding vitamin B12 intake for clients taking this medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.