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 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.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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