Which nursing assessments are important when evaluating an infant with heart failure?
(Select All that Apply.)
Monitoring for tachycardia
Observing for diaphoresis during feeding
Monitoring for polyuria
Checking for hyperthermia
Assessing for hepatomegaly
Evaluating feeding difficulties
Correct Answer : A,B,E,F
A. Monitoring for tachycardia – Correct. Tachycardia is an early sign of heart failure as the heart attempts to compensate for decreased cardiac output.
B. Observing for diaphoresis during feeding – Correct. Infants with heart failure often exhibit sweating while feeding due to increased effort and oxygen demand.
C. Monitoring for polyuria – Incorrect. Infants with heart failure are more likely to have oliguria due to poor perfusion, not excessive urination.
D. Checking for hyperthermia – Incorrect. Fever is not a primary sign of heart failure unless an infection is present.
E. Assessing for hepatomegaly – Correct. Hepatomegaly occurs due to systemic venous congestion, a hallmark of right-sided heart failure.
F. Evaluating feeding difficulties – Correct. Poor feeding and failure to thrive are common in infants with heart failure due to fatigue and respiratory distress.
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Related Questions
Correct Answer is C
Explanation
A. Allow my child to resume normal activities, including physical education, the day after the surgery. – Incorrect. Strenuous activity should be avoided for at least 1–2 weeks post-op.
B. Make sure my child takes aspirin for pain relief after the surgery. – Incorrect. Aspirin is contraindicated in children due to the risk of Reye’s syndrome.
C. Monitor my child for signs of bleeding such as frequent swallowing or vomiting blood. – Correct. Frequent swallowing can indicate bleeding from the surgical site.
D. Give my child hard, crunchy foods to eat after the surgery. – Incorrect. Soft foods are recommended to prevent irritation and bleeding.
Correct Answer is A
Explanation
A. Allow your child to participate in age-appropriate activities, such as riding a bike using proper protective gear. – Correct. Children with hemophilia can engage in non-contact activities with precautions.
B. Not allow your child to ride a bike or go skateboarding with their classmates. – Incorrect. Total restriction of activity is unnecessary and can negatively affect development.
C. Allow your child to play any sport they want to play. – Incorrect. Contact sports should be avoided to prevent bleeding episodes.
D. Not allow your child to play any sport due to the risk of injury. – Incorrect. Some activities like swimming, walking, and biking with protective gear are encouraged.
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