The nurse is assessing an infant with congestive heart failure (CHF). Which of the following symptoms would the nurse most likely find in this infant?
a. jugular vein distention c. greatly elevated blood pressure
b. peripheral edema d. diaphoresis during feeding
D
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A Incorrect. Jugular vein distention cannot be observed in infants with CHF because of their short necks.
B Incorrect. Peripheral edema is a rare finding in infants with CHF, but when present, it is usually localized to the periorbital area.
C Incorrect. The blood pressure is usually maintained in infants with CHF. Hypotension, rather than hypertension, is a late and ominous sign.
D Correct. An infant with congestive heart failure exhibits diaphoresis during feeding caused by sympathetic stimulation.
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