The nurse is caring for an infant who was recently diagnosed with a congenital heart defect.
Which assessment finding is most important for the nurse to report to the healthcare provider?
Audible heart murmur.
Heart rate of 162 beats/minute.
Poor oral intake and suckling effort.
Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
The Correct Answer is C
Infants with congenital heart defects may have difficulty with feeding due to increased effort required to breathe and feed at the same time. This can lead to poor weight gain and dehydration. Thus, it is important for the nurse to report any signs of poor feeding or oral intake to the healthcare provider. While audible heart murmur (choice A) and a high heart rate (choice B) are expected findings in infants with congenital heart defects, they do not necessarily indicate a need for immediate intervention. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours (choice D) may actually be a positive finding in an infant with a congenital heart defect, but it is not as important to report as poor oral intake and suckling effort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
Correct Answer is A
Explanation
The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause
A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.
A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.
Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.
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