Nokea
Which comment made by a parent of a 1-month-old infant would alert the nurse about the presence of a congenital heart defect?
- A. He is always hungry.'
- B. He tires out during feedings.'
- C. He is fussy for several hours every day.'
- D. He sleeps all the time.'
Correct Answer: B
Rationale: Fatigue during feedings is a common sign of congenital heart defects due to increased cardiac workload.
You may also like to solve these questions
How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue?
- A. Feeding more frequently with smaller feedings
- B. Using a soft nipple with enlarged holes
- C. Holding and cuddling the child during feeding
- D. Substituting glucose water for formula
- E. Offering high-caloric formula
Correct Answer: A,B,C,E
Rationale: Smaller, frequent feedings, soft large-holed nipples, cuddling, and high-calorie formula reduce fatigue and support nutrition in CHF.
Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
- A. A loud, harsh murmur with a systolic thrill
- B. Cyanosis when crying
- C. Blood pressure higher in the arms than in the legs
- D. A machinery-like murmur
Correct Answer: A
Rationale: A loud, harsh murmur with a systolic thrill is a hallmark sign of a ventricular septal defect in newborns.
What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham's chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: Sydenham's chorea, characterized by involuntary limb movements, is a neurological manifestation of rheumatic fever.
The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, 'How does Kawasaki disease affect my child's heart and blood vessels?' On what understanding is the nurse's response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Kawasaki disease causes vasculitis, weakening vessel walls and increasing the risk of aneurysms.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: A ventricular septal defect allows blood to shunt from the left to the right ventricle due to higher left ventricular pressure, increasing pulmonary flow without causing cyanosis.