The following is found during the assessment of a 1-month-old infant. Which of the following would lead the nurse to suspect a cardiac defect?

weight gain

hyperactivity

pink mucous membranes

poor nutritional intake

Answer and Explanation

The Correct Answer is D

A. Weight gain is typically a sign of adequate nutrition and growth, not a concern for a cardiac defect.
B. Hyperactivity is not characteristic of infants, especially at 1 month of age, and is not a common sign of a cardiac issue in this age group.
C. Pink mucous membranes indicate adequate oxygenation, which does not suggest a cardiac defect.
D. Poor nutritional intake in an infant may signal an underlying cardiac defect, particularly if accompanied by fatigue with feeding, diaphoresis, or failure to thrive. Infants with congenital heart defects often have difficulty feeding due to increased energy expenditure and reduced oxygenation, making this a key red flag.

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Correct Answer is C

Explanation

A. Digoxin does not need to be given with food, and food may actually alter its absorption. It's best given at the same time each day, either with or without food, depending on the provider's recommendation.
B. The heart rate threshold for holding digoxin in children is generally less than 90–110 beats/min in infants and less than 70 in older children, not 60 bpm, which is the adult guideline.
C. Nausea and vomiting are early signs of digoxin toxicity. Parents should be taught to observe for these symptoms and report them immediately.
D. If a child vomits after taking digoxin, the dose should not be repeated, as it is impossible to know how much was absorbed, and repeating could cause toxicity.

A. Place a bedside humidifier at the head of the client's bed. B. Suction the nasopharynx as needed. C. Perform chest physiotherapy. D. Withhold fluids until the client demonstrates a gag reflex.

Correct Answer is D

Explanation

A. A humidifier can help keep secretions moist and reduce discomfort, but it does not prevent aspiration and is not a priority in the immediate postoperative period.
B. Suctioning the nasopharynx should be done with caution after a tonsillectomy, as it can irritate the surgical site and cause bleeding; it is not a routine action to prevent aspiration.
C. Chest physiotherapy is not appropriate in the immediate postoperative period following a tonsillectomy and could increase the risk of bleeding.
D. After a tonsillectomy, the nurse should withhold oral fluids until the child is fully awake and has a demonstrated gag reflex, which helps ensure that the airway is protected and reduces the risk of aspiration.

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The following is found during the assessment of a 1-month-old infant. Which of the following would lead the nurse to suspect a cardiac defect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What anticipatory guidance should you give to the parents of a child who must take digoxin?

Correct Answer is C

Explanation

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which actions should the nurse plan to take to prevent aspiration?

Correct Answer is D

Explanation

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