An infant has undergone surgical repair of her myelomeningocele and is returned to the pediatric unit. Her mother tearfully says to the nurse, "I wish I could hold my baby.”. Which nursing action would be most appropriate?

Choice A rationale:

Periodic apneic spells of 10 seconds or less in a 10-day-old infant could be indicative of a potential respiratory issue, but it is not directly related to congenital heart defects. Apnea spells are more commonly associated with prematurity or other respiratory conditions.

Choice B rationale:

Fatigue during feeding is consistent with a congenital heart defect. Infants with heart defects often struggle to feed due to inadequate oxygen supply and increased cardiac workload. This can lead to tiring easily during feeding.

Choice C rationale:

Transient mottling of extremities can occur in infants due to immature blood vessel regulation, especially when they are cold. While some heart conditions might contribute to poor circulation, transient mottling is not a specific finding associated with congenital heart defects.

Choice D rationale:

Clubbing of fingers typically results from chronic hypoxia and is not likely to be seen in a 10-day-old infant. It takes time for chronic hypoxia to cause clubbing, so this finding is not consistent with the patient's age or condition.

Choice A rationale:

Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.

Choice B rationale:

Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.

Choice C rationale:

Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.

Choice D rationale:

Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.