The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child?
1. Hypothermia related to decreased metabolic state
2. Acute Pain related to the effects of a congenital heart defect
3. Ineffective Tissue Perfusion (peripheral) related to cyanosis secondary to congenital heart defect
4. Impaired Gas Exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
4
Explanation:
1. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
3. VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis.
4. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.
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