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 D
Explanation
Rationale:
A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.
B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.
C. Intravenous immunoglobulins are not indicated based on the current lab values.
D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.
Correct Answer is B
Explanation
Rationale:
A. Changing routines frequently might confuse the child rather than stimulate initiative.
B. Rewarding the child for showing initiative positively reinforces the behavior and encourages further development.
C. Allowing the child to make choices about playmates can foster independence but may not directly stimulate initiative.
D. Setting appropriate limits is important for a child's development, but not setting any limits can lead to behavioral issues rather than promoting initiative.