An infant is admitted to the pediatric unit with heart failure due to a congenital heart defect. What assessment finding would the nurse expect with this diagnosis?
Polyuria
Difficulty feeding
Bradycardia
Bradypnea
The Correct Answer is B
Rationale:
A. Polyuria is not commonly associated with heart failure in infants; they are more likely to have oliguria or reduced urine output.
B. Difficulty feeding is a common sign of heart failure in infants because the increased work of breathing and poor cardiac output make it hard for them to feed effectively.
C. Bradycardia is not typically associated with heart failure; tachycardia is more common as the heart tries to compensate for decreased cardiac output.
D. Bradypnea is uncommon in heart failure; tachypnea is a more likely symptom due to fluid overload and poor oxygenation.
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Correct Answer is A
Explanation
Rationale:
A. Lethargy is an early sign of increased intracranial pressure (ICP) due to possible shunt malfunction and requires immediate medical attention.
B. Seizure activity can be a late sign of shunt malfunction and is also concerning but lethargy typically appears earlier.
C. Rapid weight gain is less directly related to shunt malfunction and more associated with conditions like hypothyroidism or edema.
D. Disinterest in school could suggest general malaise but is not a specific or early sign of shunt malfunction.
Correct Answer is A
Explanation
Rationale:
A. Myelomeningocele is a type of spina bifida where there is a protrusion of the meninges and spinal cord through a defect in the vertebrae. This condition can result in partial to complete paralysis in the lower extremities due to the involvement of the spinal cord.
B. A unilateral port-wine birthmark is typically associated with conditions like Sturge-Weber syndrome, not myelomeningocele.
C. A protruding sac containing abdominal contents is characteristic of omphalocele, not myelomeningocele.
D. Fusion of cranial suture lines is not associated with myelomeningocele but rather with craniosynostosis.