(Select all that apply):.
A nurse is performing a nursing assessment on a child with a congenital heart defect.
Which aspects should the nurse include in the assessment? Select all that apply.

Choice A rationale:

Bluish discoloration of the skin, lips, or nail beds (cyanosis) is a classic symptom of cyanotic congenital heart disease (CCHD).

This occurs because of the inadequate oxygenation of the blood, which leads to oxygen-poor blood being circulated in the body.

Choice B rationale:

Poor feeding and inadequate weight gain can be associated with CCHD, especially when there is a significant reduction in cardiac output.

Infants with CCHD may have difficulty feeding due to the increased workload on their heart and may struggle to gain weight.

Choice C rationale:

Rapid breathing and shortness of breath are common symptoms in children with CCHD.

The inadequate oxygenation of the blood can lead to an increased respiratory rate and shortness of breath as the body tries to compensate for the lack of oxygen.

Choice D rationale:

Abnormal heart sounds heard during auscultation are characteristic of CCHD.

The specific type of abnormal heart sound may vary depending on the specific defect but can include murmurs, clicks, or other unusual sounds.

Choice E rationale:

Frequent respiratory infections are not typically associated with CCHD.

While children with CCHD may be more susceptible to infections due to their compromised oxygenation, it is not a direct symptom of the condition.

Choice A rationale:

The nurse's response should include teaching proper positioning techniques as optimizing a child's respiratory function can be improved by correct positioning.

Proper positioning helps ensure that the child's airways are open and not obstructed, which is essential for effective breathing.

This is a fundamental aspect of respiratory care, especially in pediatric patients who may not be able to reposition themselves if they are uncomfortable or experiencing difficulty breathing.

Choice B rationale:

Administering vasodilators is not typically a measure to optimize a child's respiratory function.

Vasodilators are medications that dilate blood vessels and are usually used in specific cardiovascular conditions to reduce the workload on the heart.

They are not directly related to optimizing respiratory function.

Choice C rationale:

Monitoring growth patterns, while important for a child's overall health, is not a direct response to the client's question about optimizing respiratory function.

Growth patterns are assessed for general development and health, but they do not specifically address respiratory function.

Choice D rationale:

Providing information on the child's condition is essential, but it does not directly address the question about optimizing respiratory function.

While education is crucial, the primary focus should be on practical measures to improve the child's respiratory function, such as proper positioning and breathing techniques.