A nurse is caring for an infant with cyanosis and a ventricular septal defect (VSD).
The nurse should expect which of the following symptoms in this patient?
"My baby's skin and lips have turned bluish.”
"My baby has difficulty feeding and is not gaining weight properly.”
"My baby gets tired quickly during physical activity.”
"I can hear abnormal heart sounds during the check-up.”
The Correct Answer is A
Choice A rationale:
The patient's statement, "My baby's skin and lips have turned bluish," is a classic symptom of cyanosis.
Cyanosis is a bluish or purple discoloration of the skin and mucous membranes, which occurs due to a lack of oxygen in the blood.
In this case, it's associated with a ventricular septal defect (VSD), which is a congenital heart defect that allows oxygen-poor blood from the right side of the heart to mix with oxygen-rich blood from the left side.
Choice B rationale:
The statement, "My baby has difficulty feeding and is not gaining weight properly," may be related to the VSD, but it is not a typical symptom of cyanosis.
This symptom can occur due to congestive heart failure in infants with VSD.
Choice C rationale:
"My baby gets tired quickly during physical activity" can also be associated with VSD and congestive heart failure, but it is not a direct symptom of cyanosis.
Choice D rationale:
"I can hear abnormal heart sounds during the check-up" is not a symptom but rather a sign of a ventricular septal defect.
Abnormal heart sounds, like a loud holosystolic murmur, may be heard on auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"I've noticed a bluish discoloration of my skin and lips" is not a typical symptom of an atrial septal defect (ASD).
ASD is a congenital heart defect that involves an abnormal opening between the atria of the heart, and it typically results in increased blood flow to the lungs, not cyanosis.
Choice B rationale:
"I find it hard to feed, and I'm not gaining weight as expected" can be related to ASD, but it is not a primary symptom.
The increased blood flow to the lungs in ASD may lead to congestive heart failure, which can cause poor feeding and inadequate weight gain.
Choice C rationale:
"I feel short of breath and tired during physical activities" is a likely symptom of ASD.
With ASD, there is an increased volume of blood being pumped into the lungs, which can lead to pulmonary congestion, shortness of breath, and fatigue.
Choice D rationale:
"The doctor mentioned hearing unusual heart sounds during the examination" is not a symptom but rather a sign of an atrial septal defect.
Unusual heart sounds, like a fixed split second heart sound, may be heard on auscultation.
Correct Answer is A
Explanation
Choice A rationale:
Cyanosis that worsens with crying or feeding is characteristic of Tetralogy of Fallot (TOF).
TOF is a congenital heart defect characterized by four specific cardiac abnormalities, one of which is a ventricular septal defect (VSD).
The VSD allows deoxygenated blood to flow from the right ventricle into the left ventricle and then into the aorta, leading to systemic cyanosis, which is exacerbated by crying or feeding due to increased right-to-left shunting.
Choice B rationale:
Severe chest pain is not a characteristic symptom of Tetralogy of Fallot (TOF).
TOF primarily presents with cyanosis and other associated symptoms related to the heart defect.
Choice C rationale:
Palpitations are not a characteristic symptom of TOF.
While some children with congenital heart defects may experience palpitations, this is not a specific hallmark of TOF.
Choice D rationale:
Frequent respiratory infections are not a characteristic symptom of TOF.
The symptoms associated with TOF are primarily related to cardiac function, such as cyanosis, and do not directly cause respiratory infections.
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