Which of the following are expected assessment findings in a child with congestive heart failure (CHF)?
Diaphoresis during feeding.
Bounding peripheral pulses.
Weight loss.
Tachycardia.
Hepatomegaly.
Correct Answer : A,D,E
Choice A rationale
Diaphoresis (sweating) during feeding in an infant is a key sign of increased sympathetic nervous system activity and extreme work of breathing due to pulmonary venous congestion. The significant physical effort required for sucking and swallowing rapidly increases oxygen consumption, triggering a stress response and signaling profound respiratory distress and cardiac compromise in congestive heart failure (CHF).
Choice B rationale
Bounding peripheral pulses are typically indicative of conditions with a wide pulse pressure (high systolic, low diastolic), such as a patent ductus arteriosus (PDA) or severe aortic regurgitation, or hyperdynamic states like fever or sepsis. Congestive heart failure (CHF) due to poor contractility generally results in diminished or thready pulses due to low cardiac output and peripheral vasoconstriction.
Choice C rationale
Weight loss or, more commonly, failure to thrive, is an expected finding due to the combination of poor caloric intake (infants fatigue easily during feeding) and the dramatically increased metabolic rate associated with the persistently high work of breathing and cardiac effort in congestive heart failure (CHF). However, fluid retention can sometimes mask this.
Choice D rationale
Tachycardia (increased heart rate, normal range varies by age) is the primary physiological compensatory mechanism in congestive heart failure (CHF) to maintain cardiac output (Cardiac Output = Stroke Volume×Heart Rate) when the stroke volume is reduced due to myocardial dysfunction or volume overload. It is an almost universally expected finding.
Choice E rationale
Hepatomegaly (enlarged liver) is a consequence of systemic venous congestion due to failure of the right side of the heart to effectively pump blood forward. The resulting increase in systemic central venous pressure causes the blood to back up into the inferior vena cava and subsequently into the hepatic veins, causing passive liver congestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
An oxygen saturation of 88.
Choice B rationale
Bounding peripheral pulses are a classic finding in Patent Ductus Arteriosus (PDA) due to the wide pulse pressure, which results from the run-off of blood from the aorta back into the pulmonary artery during diastole. This finding supports the diagnosis but is not typically the most concerning indicator of impending decompensation.
Choice C rationale
The machinery-like murmur is the pathognomonic sign of a Patent Ductus Arteriosus, caused by continuous blood flow from the high-pressure aorta to the low-pressure pulmonary artery. This is an expected diagnostic finding for PDA, confirming the presence of the defect, but it is not an indicator of acute distress.
Choice D rationale
A respiratory rate of 60 breaths per minute in a 2-month-old infant is a significant indicator of tachypnea and potential respiratory distress, likely due to pulmonary overcirculation and the resulting congestive heart failure (CHF) caused by the PDA. This elevated rate signals a critical effort to compensate for decreased pulmonary compliance and is the most immediate concern.
Correct Answer is D
Explanation
Choice A rationale
Administering half the dose is inappropriate and lacks a scientific basis unless ordered by the provider, as it would likely be sub-therapeutic and fail to achieve the desired effect of improving myocardial contractility and reducing heart rate. Digoxin administration should be all or none based on parameters.
Choice B rationale
The acceptable apical pulse rate for administering digoxin to an infant is typically above 90-110 beats per minute (bpm). An apical pulse of 88 bpm falls below this generally accepted cutoff, indicating potential drug toxicity or the therapeutic effect lowering the rate too much, necessitating withholding the dose.
Choice C rationale
Administering double the dose is a dangerous, unscientific action that would significantly increase the risk of digoxin toxicity, which can cause severe cardiac arrhythmias, gastrointestinal symptoms, and potential cardiac arrest, particularly in infants who are highly susceptible to small dose changes.
Choice D rationale
The normal heart rate for an infant is significantly higher than 88 bpm. Holding the dose and notifying the provider is the required action. Bradycardia in an infant receiving digoxin is the cardinal sign of potential toxicity or an excessively deep therapeutic effect, and the provider must assess the situation before further dosing.
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