The nurse is assessing an infant with congestive heart failure (CHF). The nurse hears rales and rhonchi, observes nasal flaring and restlessness, and finds that the oxygen saturation is falling. What does the nurse most suspect?
a. The infant has been over-medicated or undermedicated.
b. There is an increase in lung fluid or a congenital heart defect.
c. The infant has experienced a spontaneous pneumothorax.
d. There is an electrolyte imbalance and probably respiratory acidosis.
B
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A Incorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that the infant has been over-medicated or undermedicated.
B Correct. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation indicate pulmonary congestion or a congenital heart defect. As pulmonary congestion worsens, there is leaking of fluid into the alveoli and interstitium of the lung leading to pulmonary edema.
C Incorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that the infant has experienced a spontaneous pneumothorax.
D Incorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that there is an electrolyte imbalance and probably respiratory acidosis.
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