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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Answer: A

Rationale:

(A) Repair should be done before the child is potty-trained: Surgical correction of hypospadias is typically recommended before the child reaches the age of 18 months, ideally between 6 and 12 months. This timing ensures that the child has not yet developed any psychological awareness of the surgery and helps avoid complications during toilet training. Repair before potty training is important to prevent urinary dysfunction and psychosocial issues.

(B) The urethral repair should be done after sexual maturity: Delaying surgical repair until after sexual maturity is not recommended. Early repair is crucial to ensure normal urinary and sexual function, and delaying it could lead to complications such as difficulty with urination and psychological distress.

(C) Surgery should be done by one month to prevent bladder infections: While preventing urinary tract infections is important, performing surgery as early as one month is not typically necessary or recommended. The optimal timing is closer to 6 to 12 months of age when the child is more resilient to surgery but still before the developmental milestones of potty training.

(D) Delaying the repair until school age reduces castration fears: Delaying the surgery until school age can actually increase psychological stress and fear of castration. Early surgical correction is preferred to minimize psychological impact and to allow the child to develop normally without the need for complex explanations or fear of surgery later in life.

A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks. B. Measure the child's blood pressure three times during the visit and determine the highest of the readings. C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination. D. Take the blood pressure two more times during the visit and determine the average of the three readings.

Correct Answer is D

Explanation

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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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?

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Naxlex Comprehensive Predictor Exams

The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. Which information should the nurse provide?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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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?