The nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)?
1. Pallor
2. Strong sucking reflex
3. Diaphoresis during feeding
4. Slow and shallow breathing
3
Rationale: The early symptoms of CHF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Pallor may be noted in the infant with CHF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of CHF.
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