A two-month-old infant is hospitalized for repair of a ventricular septal defect. The infant's admitting diagnosis is moderate congestive heart failure. What signs and symptoms would you expect to see in your assessment?
Bradycardia, bounding pulses, cyanosis
Overdiuresis, increased appetite, increased thirst
Wheezing, pallor, capillary refill time < 2 seconds
Tachypnea, cough, tachycardia
The Correct Answer is D
Choice A reason: This is not a correct statement, as bradycardia, bounding pulses, and cyanosis are not typical signs and symptoms of moderate congestive heart failure. Bradycardia may indicate a heart block or a vagal response, bounding pulses may indicate a patent ductus arteriosus or aortic regurgitation, and cyanosis may indicate a severe right-to-left shunt or a pulmonary embolism¹.
Choice B reason: This is not a correct statement, as overdiuresis, increased appetite, and increased thirst are not typical signs and symptoms of moderate congestive heart failure. Overdiuresis may indicate a renal dysfunction or a diuretic overdose, increased appetite may indicate a normal growth spurt or a metabolic disorder, and increased thirst may indicate dehydration or diabetes¹.
Choice C reason: This is not a correct statement, as wheezing, pallor, and capillary refill time < 2 seconds are not typical signs and symptoms of moderate congestive heart failure. Wheezing may indicate a bronchospasm or an asthma attack, pallor may indicate anemia or shock, and capillary refill time < 2 seconds may indicate a normal or increased peripheral perfusion¹.
Choice D reason: This is the correct statement, as tachypnea, cough, and tachycardia are typical signs and symptoms of moderate congestive heart failure. Tachypnea may indicate a respiratory distress or a pulmonary edema, cough may indicate a fluid accumulation or an infection in the lungs, and tachycardia may indicate a compensatory mechanism or a cardiac arrhythmia¹².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Unfamiliar equipment should be shown to the child and the family before the surgery, as part of the preoperative education and preparation. This can help reduce the child's fear and anxiety, as well as increase the child's understanding and cooperation during the surgery¹.
Choice B reason: Explain that an endotracheal tube will be needed for the surgery, regardless of how well it goes. The endotracheal tube is inserted through the mouth or nose into the trachea to provide mechanical ventilation during the surgery and the immediate postoperative period. The child and the family should be informed about the purpose, duration, and possible complications of the endotracheal tube, as well as the methods of communication and comfort measures².
Choice C reason: Mention the postoperative discomfort and interventions that the child may experience after the surgery, such as pain, nausea, chest tubes, drains, dressings, and monitors. The child and the family should be reassured that these are normal and expected, and that the nurse will provide adequate pain relief and care. The child and the family should also be taught about the postoperative activities and exercises, such as deep breathing, coughing, turning, and leg movements, to promote recovery and prevent complications³.
Choice D reason: Let the child hear the sounds of an ECG monitor, as well as other equipment that will be used during the surgery, such as a blood pressure cuff, an oxygen mask, and an IV pump. This can help familiarize the child with the sounds and sensations that he or she will encounter during the surgery, and reduce the fear of the unknown. The child should also be encouraged to ask questions and express feelings about the surgery⁴.
Correct Answer is A
Explanation
Choice A reason: Encouraging and helping mother to breastfeed is a supportive and beneficial nursing intervention for a mother who has given birth to an infant with a cleft palate. Breastfeeding provides optimal nutrition, immunity, and bonding for the infant, and may also help prevent infections and promote healing of the cleft. Breastfeeding may be possible for some infants with cleft palate, especially if the cleft is mild or only affects the soft palate. The nurse should assist the mother with positioning, latching, and using devices such as a nipple shield, a breast pump, or a supplemental nursing system. The nurse should also monitor the infant's weight gain, hydration, and output, and provide emotional support and education to the mother.
Choice B reason: Teaching mother to feed breast milk by gavage is not a necessary or desirable nursing intervention for a mother who has given birth to an infant with a cleft palate. Gavage feeding is a method of providing nutrition through a tube that is inserted through the nose or mouth into the stomach. It is usually used for infants who have severe feeding difficulties or other medical conditions that require tube feeding. However, most infants with cleft palate can be fed orally with proper techniques and equipment, and do not need gavage feeding. Gavage feeding may have complications such as infection, irritation, displacement, or obstruction of the tube. It may also interfere with the infant's oral development and bonding with the mother.
Choice C reason: Giving medication to suppress lactation is not a helpful or respectful nursing intervention for a mother who has given birth to an infant with a cleft palate. Medication to suppress lactation is a drug that inhibits the production of breast milk. It is usually used for mothers who choose not to breastfeed or who have medical contraindications to breastfeeding. However, a cleft palate is not a contraindication to breastfeeding, and the mother may still want to breastfeed or express breast milk for her infant. Giving medication to suppress lactation may cause side effects such as nausea, headache, or depression. It may also deprive the infant of the benefits of breast milk, and the mother of the choice and satisfaction of breastfeeding.
Choice D reason: Providing mother with the appropriate formula for the patient is not a sufficient or comprehensive nursing intervention for a mother who has given birth to an infant with a cleft palate. Formula is an artificial substitute for breast milk that provides nutrition for infants who cannot or do not breastfeed. Formula may be used for infants with cleft palate, especially if breastfeeding is not possible or adequate. However, formula does not provide the same immunity, protection, and bonding as breast milk. Providing formula alone does not address the mother's needs, preferences, or feelings about feeding her infant. The nurse should also offer other options, such as expressing breast milk, using a special bottle or cup, or combining breastfeeding and formula feeding. The nurse should also teach the mother how to prepare, store, and administer the formula safely and hygienically.
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