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. 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.
Correct Answer is B
Explanation
A) Incorrect. Encouraging high-intensity aerobic exercises daily is not appropriate for a client with a congenital heart disease, as it can put excessive strain on the heart and may not be safe.
B) The answer is B. Limiting physical activities to mild exercises and avoiding competitive sports is recommended for clients with congenital heart diseases to prevent overexertion and potential complications.
C) Incorrect. Complete restriction of physical activity for six months is not necessary for most clients with congenital heart diseases. It is essential to promote safe and appropriate physical activities.
D) Incorrect. Activities with prolonged standing may increase venous return and potentially worsen certain congenital heart conditions. The focus should be on low to moderate intensity exercises.
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