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. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.

Rationale:

A) Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread: This is the primary reason why surgery is performed before a biopsy in cases of Wilms tumor. The tumor is usually encapsulated, and performing a biopsy could risk breaking the capsule, leading to the dissemination of cancer cells into surrounding tissues, which can worsen the prognosis.

B) Metal clips are surgically applied at the tumor site for exact marking for radiation: While marking the tumor site for radiation is important, it is not the primary reason for performing surgery before a biopsy. The main concern is about the potential for cancer cell spread during a biopsy procedure.

C) Surgery is necessary to stage the tumor and determine metastasis to other sites: Although staging is a critical aspect of cancer management, the urgency of avoiding tumor rupture and subsequent spread is more pressing in this context. The surgery may assist in staging, but that is not the primary reason for immediate surgical intervention.

D) The surgery provides a visualization of other pathology and dysfunction of the kidney: While the surgical procedure may provide additional information about the kidney's condition, the most significant concern regarding Wilms tumor is preventing tumor rupture and the consequent spread of cancer cells, making this option less relevant.

A. Cross the arms and legs. B. Perform a log roll. C. Raise the hips. D. Flex the knees.

Correct Answer is B

Explanation

When moving an adolescent with scoliosis who is recovering after a surgical spinal instrumentation, the nurse should use the log roll technique. This technique involves keeping the spine in alignment while turning the client onto their side. Crossing the arms and legs, raising the hips, and ﬂexing the knees are not appropriate techniques for moving a client with spinal instrumentation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?

Correct Answer is A

Explanation

The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?

Correct Answer is B

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?