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The nurse completes documentation on the client who is 10 hours post initial digitalization dose and furosemide dose.

Click to highlight the findings that indicate the client is progressing as expected.

Nurses Notes

1700

The client is post digitalization and furosemide. Client is being held by his parent. Infant can feed on demand. Lungs are clear to auscultation, and no accessory muscle use is noted. Shows no signs of cyanosis. Is feeding for 15 minutes every three hours using a 28 cal/oz (28 cal/30 mL) formula. His urine is clear, and the specific gravity is low. The client continues to have a loud holosystolic murmur noted. Pulses are 1+ through all extremities. Parents are at the bedside and are verbalizing their understanding of current care needs.

Lungs are clear to auscultation, and no accessory muscle use is noted

Shows no signs of cyanosis

Is feeding for 15 minutes every three hours using a 28 cal/oz (28 cal/30 mL) formula

His urine is clear, and the specific gravity is low

The client continues to have a loud holosystolic murmur noted

Pulses are 1+ through all extremities

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Rationale for correct answers:

Lungs are clear to auscultation, and no accessory muscle use is noted: This is a primary indicator that the furosemide has successfully reduced pulmonary edema. At 0900, the infant had coarse breath sounds and tachypnea; clear lungs and easy breathing show the heart is no longer "failing" to pump fluid away from the lungs.
Shows no signs of cyanosis: The resolution of the "mild cyanosis" noted at admission indicates that gas exchange has improved and the infant’s oxygen demand is being met.
Is feeding for 15 minutes every three hours using a 28 cal/oz (28 cal/30 mL) formula: For an infant with VSD, feeding is "work." Being able to finish a feeding in 15 minutes without diaphoresis or fatigue (unlike the "refusal to eat" at 0900) proves improved cardiac reserve. The high-calorie formula helps address the "failure to thrive" by providing more energy in smaller volumes.
His urine is clear, and the specific gravity is low: This indicates that the kidneys are being well-perfused (adequate cardiac output) and that the diuretic (furosemide) is effectively promoting the excretion of dilute urine to resolve fluid volume excess.

Rationale for incorrect choices:

The client continues to have a loud holosystolic murmur noted: This is an expected but unchanging finding. The murmur is caused by the physical hole in the heart (VSD). Medications do not fix the structural defect, so the murmur will persist until the VSD is surgically closed or closes on its own.
Pulses are 1+ through all extremities: This is actually a suboptimal finding. Pulses should ideally be 2+. 1+ pulses may indicate that cardiac output is still slightly low or that the infant is still recovering from the acute phase of heart failure.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Taking an analgesic and exposing the breasts to air may provide temporary comfort but does not address the underlying cause of engorgement. Air exposure can sometimes stimulate milk production, worsening engorgement in a bottle-feeding client.

B. Expressing milk by hand relieves engorgement but can stimulate lactation. For a client who is bottle feeding and not intending to breastfeed, this may prolong or increase milk production, which is not desirable.

C. Placing warm packs on the breasts can promote milk let-down and increase engorgement, making the discomfort worse. Warmth is generally recommended for breastfeeding clients to facilitate milk flow, not for those who are weaning or bottle feeding.

D. This is the most appropriate recommendation. Avoiding breast stimulation (such as massaging or expressing milk) and wearing a supportive, tight-fitting bra helps reduce blood flow and milk production, allowing the breasts to gradually regress. Cold compresses can also be applied to relieve discomfort. These interventions decrease swelling and tenderness without promoting further milk production.

A. Peripheral pallor of the skin. B. Increased heart rate. C. Clenched fists. D. Increased respiratory rate. E. Restlessness. F. Increased temperature.

Correct Answer is ["B","C","D","E"]

Explanation

A. Changes in skin color, such as paleness, can reflect stress, temperature changes, or poor perfusion but are not specific indicators of pain in infants. Pallor alone should not trigger analgesic administration without other supporting signs.

B. Tachycardia is one of the most sensitive early physiological responses to pain in infants. Pain stimulates the sympathetic nervous system, leading to an increase in heart rate. Monitoring heart rate trends post-operatively is essential to detect pain early, especially after procedures like pyloromyotomy.

C. Clenched fists, along with rigid or tense posture, are classic behavioral signs of pain in infants. Nonverbal cues such as limb movements, facial grimacing, and fist clenching are reliable indicators that the infant is experiencing discomfort and may require analgesics.

D. Pain activates the sympathetic nervous system, causing tachypnea. Increased respiratory rate in combination with other behavioral signs strengthens the indication that the infant is in pain.

E. Irritability, difficulty settling, and continuous movement are common behavioral manifestations of pain in nonverbal infants. Restlessness is often the first observable sign and should prompt assessment and intervention.

F. Fever is primarily an indicator of infection or systemic inflammation, not pain. While it may accompany post-operative conditions, an elevated temperature alone does not justify analgesic administration unless other pain indicators are present.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartal client who is bottle feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Correct Answer is D

Explanation

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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