Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infant's 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
d. Positioned in high Fowler position to maintain oxygen saturation at 90%
ANS: C
Appropriate weight gain for an infant is indicative of successful feeding and a reduction in caloric loss secondary to the HF. Irritability is a symptom of HF. The child also uses additional energy when irritable. Capillary refill should be brisk and within 2 to 3 seconds. The child needs to be positioned upright to maintain oxygen saturation at 90%. Positioning is helping to decrease respiratory effort, but the infant is still having difficulty with oxygenation.
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