A 4-month old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest . The nurse is aware this finding can be attributed to:

Correct Answer: C

Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.

Correct Answer: B

Rationale: The baby's symptoms of shakiness, confusion, irritability, and slurred speech are indicative of hypoglycemia, which is low blood sugar. In a baby with newly diagnosed diabetes, the administration of insulin or oral hypoglycemic agents may have led to excessive lowering of blood glucose levels, causing these symptoms to manifest. It is crucial to address hypoglycemia promptly by administering a rapid-acting carbohydrate source such as glucose gel or juice to raise blood sugar levels back to normal range. Left untreated, severe hypoglycemia can lead to seizures, loss of consciousness, and potential long-term neurological damage. It is important for healthcare providers and caregivers to be vigilant in monitoring blood glucose levels in babies newly diagnosed with diabetes to prevent episodes of hypoglycemia.

Correct Answer: D

Rationale: Trendelenburg's sign is not a typical sign of congenital hip dysplasia. Trendelenburg's sign indicates weakness of the hip abductor muscles and is seen when a person stands on one leg and the pelvis on the unsupported side drops. The other options are more commonly associated with congenital hip dysplasia:

Correct Answer: C

Rationale: Nephrosis in children is also known as nephrotic syndrome, which is characterized by the presence of albuminuria (loss of protein in the urine), hypoproteinemia (low levels of protein in the blood), and edema (swelling due to fluid retention). This condition results from damage to the filters in the kidneys, leading to increased permeability and loss of protein in the urine. The classic triad of symptoms in nephrotic syndrome includes proteinuria, hypoalbuminemia, and edema. Other symptoms may include weight gain, frothy urine, and susceptibility to infections. Hematuria, hyperlipidemia, and hypertension are not typical features of nephrotic syndrome in children.

Correct Answer: B

Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.