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.
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Related Questions
Correct Answer is A
Explanation
A) The answer is A. Weight gain of 1 pound in a week can indicate fluid retention, which may be a sign of digoxin toxicity. The nurse should instruct the client to report this symptom immediately to prevent further complications.
B) Incorrect. A heart rate below 100 beats per minute is within the normal range for most clients. A lower heart rate is often expected in clients taking digoxin, and it does not require immediate reporting unless accompanied by other concerning symptoms.
C) Incorrect. Occasional episodes of diarrhea are common side effects of digoxin. The client should report persistent or severe diarrhea, but occasional episodes may not be a cause for immediate concern.
D) Incorrect. Mild swelling of the ankles after activity is not directly related to digoxin use. The nurse should monitor the client's ankles for any worsening swelling, but it does not require immediate reporting unless accompanied by other concerning symptoms.
The answer is A
Correct Answer is A
Explanation
A) The answer is A. Mild cyanosis during crying or feeding can indicate inadequate oxygenation and increased workload on the heart. This symptom requires immediate intervention to ensure proper oxygen supply to vital organs.
B) Incorrect. Occasional heart palpitations may not be a severe concern and may not require immediate intervention. However, the healthcare provider should still be notified for further evaluation.
C) Incorrect. Fatigue after physical activity is common in clients with congenital heart diseases due to compromised cardiac function. Although it needs attention, it does not require immediate intervention.
D) Incorrect. A heart murmur audible throughout systole and diastole can indicate structural heart abnormalities. While it requires medical follow-up, it may not need immediate intervention unless accompanied by other concerning symptoms.
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