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
A) Correct answer. Regular prenatal care, including fetal echocardiography, allows for early detection of certain congenital heart diseases in the fetus. This enables appropriate management and planning for the baby's care after birth.
B) This option is incorrect. While prenatal care is essential for overall maternal and fetal health, it is not related to heart transplant considerations.
C) This option is incorrect. Congenital heart diseases can be detected during pregnancy through fetal echocardiography and other diagnostic tests.
D) This option is incorrect. Prenatal care involves monitoring the health and development of the fetus and aims to address potential issues to ensure a healthy pregnancy and baby, including the early detection and management of congenital heart diseases.
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