Nokea
Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infants status, which finding is indicative of achieving this goal?
- A. Irritability when awake
- B. Capillary refill of more than 5 seconds
- C. Appropriate weight gain for age 18
- D. Positioned in high Fowler position to maintain oxygen saturation at 90%
Correct Answer: C
Rationale: Appropriate weight gain indicates successful feeding and reduced caloric loss, reflecting decreased cardiac demand. Irritability and prolonged capillary refill suggest ongoing HF, and high Fowler positioning aids breathing but doesn?t confirm reduced cardiac strain.
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The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication?
- A. Hypoxemia
- B. Right-to-left shunt of blood
- C. Decreased workload on the left side of the heart
- D. Pulmonary vascular congestion
Correct Answer: D
Rationale: PDA causes left-to-right shunting from the aorta to the pulmonary artery, leading to pulmonary vascular congestion. Surgery prevents this complication. Hypoxemia is linked to mixed flow defects, the shunt is left-to-right, and PDA increases left heart workload.
A chest radiography examination is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the x-ray show about the heart? The nurses response should be based on knowledge that the radiograph provides which information?
- A. Shows bones of the chest but not the heart
- B. Evaluates the vascular anatomy outside of the heart
- C. Shows a graphic measure of electrical activity of the heart
- D. Supplies information on heart size and pulmonary blood flow patterns
Correct Answer: D
Rationale: Chest radiographs reveal heart size and pulmonary blood flow patterns, aiding in cardiac assessment. They also show chest bones, but the heart is visible. Vascular anatomy is evaluated via MRI, and electrical activity is measured by electrocardiography, not radiographs.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time?
- A. Administer oxygen.
- B. Record data on the nurses notes.
- C. Report data to the practitioner.
- D. Place the child in the high Fowler position.
Correct Answer: C
Rationale: A sleeping pulse over 160 beats/min suggests tachycardia, an early sign of heart failure due to sympathetic stimulation, requiring practitioner evaluation. Oxygen or positioning may be needed later, but reporting is the priority. Recording alone delays intervention.
What drug is an angiotensin-converting enzyme (ACE) inhibitor?
- A. Furosemide (Lasix)
- B. Captopril (Capoten)
- C. Chlorothiazide (Diuril)
- D. Spironolactone (Aldactone)
Correct Answer: B
Rationale: Captopril is an ACE inhibitor used in heart failure management. Furosemide is a loop diuretic, chlorothiazide acts on distal tubules, and spironolactone is a potassium-sparing diuretic, none of which are ACE inhibitors.
After returning from cardiac catheterization, the nurse monitors the childs vital signs. The heart rate should be counted for how many seconds?
- A. 15
- B. 30
- C. 60
- D. 120
Correct Answer: C
Rationale: Counting the heart rate for 60 seconds ensures accurate detection of arrhythmias or bradycardia. Shorter durations (15 or 30 seconds) are insufficient, and 120 seconds is unnecessarily long for routine assessment.