Try Naxlex NCLEX-RN (Free-Trial)

Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)

A.

Tachypnea

B.

Wheezes or rales

C.

Bounding pulses

D.

Edematous

E.

Difficulty feeding

F.

Increased comfort laying down

Answer and Explanation

Correct Answer : A,B,D,E

A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","C","D"]

Explanation

A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.

Correct Answer is ["D","E","F"]

Explanation

A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register