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 D
A. Many infants with congenital heart defects exhibit audible murmurs due to turbulent blood flow through abnormal openings or stenotic valves. While a murmur is a diagnostic hallmark of the condition, it is often an expected finding and does not necessarily indicate acute physiological deterioration. The nurse must document the murmur, but it is rarely the most urgent finding to report.
B. A heart rate of 162 beats/minute in an infant is slightly elevated above the typical resting range but can be triggered by crying, feeding, or baseline cardiac stress from the defect. Although tachycardia requires close monitoring to ensure the infant is not entering a state of high-output failure, it is less critical than signs of fluid overload. It represents a compensatory mechanism rather than an immediate life-threatening complication.
C. Infants with cardiac defects often experience fatigue during feeding because of the high metabolic demand and decreased cardiac output. Poor suckling effort and inadequate oral intake are common symptoms of pediatric heart failure that lead to failure to thrive over time. While this finding is significant for long-term nutritional management, it does not suggest an acute, rapid shift in stability like sudden weight changes.
D. Rapid weight gain of 1 kg within 48 hours is the most critical finding because it indicates acute fluid volume excess and potential congestive heart failure. In an infant, such a significant increase is almost certainly due to fluid retention rather than nutritional growth. This clinical sign suggests that the heart is unable to manage the systemic or pulmonary circulation effectively, necessitating immediate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the affected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.
Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.
Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.
Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.
Correct Answer is C
Explanation
Acute rheumatic fever is a serious inflammatory condition that can develop after a streptococcal infection, particularly if the infection is not treated or resolved properly. The most common initial symptom of acute rheumatic fever is a sore throat, which is usually accompanied by a fever and swollen lymph nodes.
While mumps, chickenpox, and influenza are all infectious diseases, they are not directly linked to the development of acute rheumatic fever. However, a recent or untreated streptococcal infection (such as strep throat) can lead to the development of acute rheumatic fever.
Therefore, when obtaining a health history from a child with a diagnosis of acute rheumatic fever, it is most significant to inquire about recent or untreated sore throat, as this is the most likely cause of the condition.
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