What nursing action is appropriate to take when an infant with a congenital heart defect has increased respiratory rate, is sweating, and is not feeding well?
Check the infant’s temperature
Alert the physician
Increase the oxygen rate
Withhold oral feeding
The Correct Answer is B
A. Checking temperature is important, but these signs are more concerning for cardiac decompensation rather than infection.
B. The child may be experiencing heart failure or respiratory distress. Alerting the physician is the appropriate action to assess for worsening condition.
C. Increasing the oxygen rate might be necessary, but the priority is alerting the physician first for further assessment.
D. Withholding oral feeding may be necessary, but the priority is physician notification to guide management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The correct management involves obtaining blood cultures to identify the causative organism, starting high-dose antibiotics for treatment, and assessing for cardiac decompensation as the condition progresses.
B. While CBC and CXR may be ordered, starting aspirin is not a first-line treatment for infective endocarditis.
C. Cyanosis and high-dose steroids are not immediate interventions for infective endocarditis.
D. The first priority is antibiotics and blood cultures, not starting oxygen right away unless the child is hypoxic.
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
Inability to stay latched to the breast is concerning because it reflects increased work of breathing or fatigue. Infants often show feeding difficulties as an early sign of respiratory compromise, and in this case, poor feeding may also contribute to dehydration and hypoglycemia.
Capillary refill greater than 4 seconds suggests delayed peripheral perfusion, which can indicate dehydration or early shock. This is a red flag in infants and requires prompt assessment of circulatory status.
Intermittent wheezing in both lungs is an abnormal breath sound typically associated with airway narrowing or obstruction, as seen in bronchiolitis or reactive airway disease. It requires close monitoring for worsening respiratory effort or decreased air exchange.
Heart rate of 178 beats per minute is elevated for a 10-week-old infant (normal is generally 100–160 bpm). This tachycardia may be a response to fever, hypoxia, respiratory distress, or dehydration, and should be evaluated in the context of other clinical signs.
Oxygen saturation of 92% on room air is below the expected range for a healthy infant (typically ≥95%). This indicates hypoxemia, and supplemental oxygen and further respiratory support may be necessary.
Respiratory rate of 65 breaths per minute exceeds the normal range for this age (30–60 breaths/min). Tachypnea can reflect respiratory distress and is especially concerning when paired with other abnormal findings.
Mild intercostal retractions are a sign that the infant is using accessory muscles to breathe, which indicates increased work of breathing. Even mild retractions in a young infant warrant close observation.
Restlessness and head bobbing are signs of significant respiratory distress. Head bobbing is particularly concerning as it indicates fatigue and the use of neck muscles to assist with breathing, which can precede respiratory failure.
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