The nurse assessing a child with a congenital heart defect should include which of the following when assessing the cardiac status?
1. Observe for abdominal distention
2. Inspect the chest for heaving
3. Auscultate breath sounds
4. Measure urine output
2. Inspect the chest for heaving
Rationale:
The nurse should inspect the client's chest for heaving, which is a lifting of the chest during contractions. Observing for abdominal distention would be done during the assessment of the client's fluid status. Auscultating breath sounds would be included in the assessment of the respiratory status. Measuring urine output is not a feature of any particular status and may or may not need to be done.
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