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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"Long-term monitoring will include regular follow-up appointments with the cardiologist.”.
Choice A rationale:
Stating, "It's essential to schedule cardiac rehabilitation sessions for your child," is not accurate for the long-term management of a congenital heart defect.
Cardiac rehabilitation is typically recommended for individuals who have experienced a cardiac event, such as a heart attack, but it is not a standard part of the long-term management of congenital heart defects in children.
Choice B rationale:
Informing the client that long-term monitoring will include regular follow-up appointments with the cardiologist is The correct nursing response.
Regular follow-up appointments are essential for monitoring the child's heart condition, adjusting treatment as needed, and ensuring their overall well-being.
This choice is accurate and aligned with best practices.
Choice C rationale:
Stating, "You can discontinue all medications once your child reaches a certain age," is not accurate or safe advice.
The need for medications in the management of a congenital heart defect is determined by the child's specific condition and the recommendations of the healthcare team.
Discontinuing medications without medical guidance can be dangerous and is not a standard practice.
Choice D rationale:
Claiming, "Balloon valvuloplasty will be the primary treatment for long-term management," is not a universally applicable statement.
The choice of treatment for long-term management of a congenital heart defect depends on the specific diagnosis and clinical circumstances.
While balloon valvuloplasty may be a suitable treatment in some cases, it is not the primary treatment for all congenital heart defects.
Individualized care plans are developed based on the child's condition.
Therefore, this statement is not accurate as a general rule.
Correct Answer is C
Explanation
Choice A rationale:
Measuring the level of oxygen in a child's blood does not help assess the electrical activity of the heart.
Oxygen measurement and the assessment of heart electrical activity are two separate concepts.
Choice B rationale:
Measuring oxygen levels in the blood primarily evaluates the child's oxygen saturation, not the respiratory rate and effort.
While oxygen saturation is related to respiratory function, it doesn't directly assess the rate and effort of breathing.
Choice C rationale:
Measuring the level of oxygen in a child's blood monitors oxygen saturation using pulse oximetry.
Pulse oximetry is a non-invasive method used to measure the percentage of oxygen saturation in the blood.
This is important because it provides information about the child's oxygen levels, which is crucial for assessing their respiratory and circulatory status.
Choice D rationale:
Measuring the level of oxygen in the blood does not measure the child's weight and developmental milestones.
This response is unrelated to the purpose of monitoring oxygen levels in the blood.
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