The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse would expect to note documentation of which of the following most common assessment findings?
1. Cyanosis
2. Severe bradycardia
3. Asymptomatic findings
4. Higher than normal body weight
1
Rationale: The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. "Severe bradycardia" and "asymptomatic findings" are inaccurate. Many children with a left-to-right shunt may remain asymptomatic. "Higher than normal body weight" is incorrect, because these children usually have lower than normal body weight.
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a. maintain healthy weight, limit sodium intake, exercise regularly, take meds as ordered b. lose 20 pounds, weigh daily at home, report weight gain of more than 1 pound to the physician c. see the doctor weekly, take meds as ordered, limit sodium intake d. keep blood pressure at 160/90, eat a diet low in fats, exercise twice per week
Which of the following documentation entries is an example of objective data?
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1. normal weight 2. overweight 3. obese 4. metabolic syndrome
A nurse is caring for an infant with neonatal abstinence syndrome. Which manifestation should the nurse expect to assess?
a. Weight gain b. Respiratory acidosis c. High-pitched persistent cry d. Hypotonus