An infant is admitted to the pediatric unit with heart failure due to a congenital heart defect. What assessment finding would the nurse expect with this diagnosis?
Polyuria
Difficulty feeding
Bradycardia
Bradypnea
The Correct Answer is B
A. Polyuria is not commonly associated with heart failure in infants; they are more likely to have oliguria or reduced urine output.
B. Difficulty feeding is a common sign of heart failure in infants because the increased work of breathing and poor cardiac output make it hard for them to feed effectively.
C. Bradycardia is not typically associated with heart failure; tachycardia is more common as the heart tries to compensate for decreased cardiac output.
D. Bradypnea is uncommon in heart failure; tachypnea is a more likely symptom due to fluid overload and poor oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
Correct Answer is B
Explanation
A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.
B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.
C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.
D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.
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