What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well?
a. Recheck the infant's blood pressure. c. Withhold oral feeding.
b. Alert the physician. d. Increase the oxygen rate.
ANS: B
These are signs of early congestive heart failure, and the physician should be notified. Although rechecking blood pressure may be indicated, it is not the priority action. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms; however, medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action.
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