An appropriate nursing action to include in the care of an infant with congenital heart disease who has been admitted with heart failure is:

Correct Answer: C

Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.

Correct Answer: D

Rationale: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. The initial treatment for DKA requires correcting dehydration and electrolyte imbalances. Normal saline infusion is the preferred choice for initial fluid resuscitation in patients with DKA to address dehydration and restore intravascular volume. It helps improve organ perfusion and correct electrolyte imbalances such as hyponatremia and dehydration commonly seen in DKA patients. Administering normal saline helps replace lost fluids and improve circulation, which is crucial in the management of DKA. Potassium infusion may be needed later to replete potassium levels once the patient's kidney function has been assessed. NPH insulin infusion is not the initial treatment for DKA, although insulin therapy is an essential component of DKA management. 5% dextrose infusion is contraindicated in the initial treatment

Correct Answer: C

Rationale: Positioning the child on his right side after surgery for pyloric stenosis helps to promote the flow of formula through the pylorus and into the intestines. Placing the child in this position can aid in preventing any potential complications from the surgery and promote proper digestion. The right side position assists in the drainage of the stomach contents, thereby reducing the risk of complications related to the surgery and promoting the healing process. It is essential to follow this positioning recommendation as part of the post-operative care for a child who has undergone surgery for pyloric stenosis.

Correct Answer: A

Rationale: The most dangerous complication of untreated hypothyroidism is mental retardation, especially in infants and children. Thyroid hormones play a vital role in the brain development of infants and young children. Severe and prolonged hypothyroidism during this critical period can lead to irreversible cognitive impairment, affecting intelligence and neurodevelopment. Therefore, timely diagnosis and treatment of hypothyroidism are essential to prevent this serious complication, particularly in children.

Correct Answer: B

Rationale: A newborn with normal respiratory breathing would typically exhibit regular breathing patterns, with abdominal movements indicating effective diaphragmatic breathing. The normal respiratory rate for a newborn is considered to be 25 to 35 breaths per minute. Therefore, documenting the newborn's respiratory breathing as "Regular, abdominal, 25 to 35 breaths/min" would accurately represent a normal finding.