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A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

A.

Bradycardia

B.

Weight loss

C.

Orthopnea

D.

Increased urine output

Answer and Explanation

The Correct Answer is C

A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.  

 

B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.  

 

C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function. 

 

D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.


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View Related questions

Correct Answer is C

Explanation

A. By age 6, while children can dress themselves, they may still need assistance with more complex grooming tasks, making this statement too absolute.

B. Counting backwards from 20 to 1 is typically expected by age 8, not age 7, indicating this statement is inaccurate regarding cognitive development.

C. Engaging in motor activities that require balance, such as jumping rope, is appropriate for children around age 6, demonstrating the expected physical development in this age group.

D. While children can use simple tools, mastery and effective use of tools like a screwdriver or hammer are more typical around ages 8 to 10, making this statement premature for age 6.

Correct Answer is D

Explanation

A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.

B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.

C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.

D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.

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