resp & cardiac ATI
A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when I'm in my child's room." D. "I will apply lotion to my child's peeling hands."
Correct Answer: A. "My child may take aspirin for his joint pain." Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints. Incorrect Answers: B. A child who has rheumatic fever does not require blood transfusions since there is no blood loss from this disorder. C. A child who has rheumatic fever only needs standard isolation precautions. Rheumatic fever is an immune response that occurs after an infection with group A β-hemolytic streptococci. D. Kawasaki disease causes peeling hands, but rheumatic fever does not.
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake B. Decrease the child's calorie intake C. Increase the child's fiber intake D. Decrease the child's salt intake
Correct Answer: A. Increase the child's protein intake The nurse should recommend an increased protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowance to meet their nutritional needs. Incorrect Answers: B. The calorie intake for a child who has cystic fibrosis should be increased, not decreased. C. Increasing the child's fiber intake could increase bulk, and malabsorption might occur; therefore, it is not indicated for this child. D. Decreasing the child's salt intake is not indicated for cystic fibrosis.
A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine
Correct Answer: A. Place the infant in knee-chest position The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery. Incorrect Answers: B. The nurse should identify that a hypercyanotic spell is a temporary period of hypoxia that can occur in response to crying, feeding, or straining during a bowel movement. The nurse should not initiate CPR because the infant is still breathing and has a pulse. C. The nurse should administer 100% oxygen via facemask to treat the hypoxia that occurs during a hypercyanotic spell. D. The nurse should not administer adenosine to an infant experiencing a hypercyanotic spell. Adenosine is an antiarrhythmic used in the treatment of supraventricular tachycardia.
A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care
Correct Answer: B. Alcohol consumption Alcohol consumption is a maternal risk factor for the development of congenital heart disease. Incorrect Answers: A. Preeclampsia is not a maternal risk factor for the development of congenital heart disease. C. Placenta previa is not a maternal risk factor for the development of congenital heart disease. D. While late prenatal care is not optimal for prenatal care and outcomes, it is not a maternal risk factor for the development of congenital heart disease.
A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations? A. Orthopneic B. Knee-chest C. Sims' D. Semi-Fowler's
Correct Answer: B. Knee-chest The knee-chest position, which is similar to squatting, facilitates the oxygenation of the lungs. The nurse should assist the child into this position to facilitate breathing. Incorrect Answers: A. Orthopneic positioning is not likely to help a child who has a cardiac defect and is having difficulty breathing. However, it can help clients who have respiratory difficulties. C. Sims' position is not likely to help a child who has a cardiac defect and is having difficulty breathing. It is generally used when exposure of the rectal area is required. D. Semi-Fowler's position does promote lung expansion, but this client's difficulty is cardiac in nature, not respiratory.
A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication follows a certain schedule to help you sleep better."
Correct Answer: C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." A 9-year-old child should understand that the production of thick mucus is a part of the disease process. Incorrect Answers: A. School-age children do not engage in abstract thought and reasoning because they are unable to grasp the reality of long-term consequences. This statement would be appropriate for an adolescent client. B. School-age children want to understand how things work. Any explanation should include appropriate scientific and medical terminology. D. This statement does not explain the pathophysiology of cystic fibrosis, why it interferes with sleep, or how the medicine will help.
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen
Correct Answer: C. Amoxicillin A child who has acute otitis media should take an antibiotic to help alleviate the infection. Incorrect Answers: A. Diphenhydramine is an antihistamine used for allergic reactions. B. Furosemide is a diuretic used to decrease edema. D. Children who are <6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 sec, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 sec interval." D. "I will record the highest reading of three attempts."
Correct Answer: D. "I will record the highest reading of three attempts." After establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3. Incorrect Answers: A. The nurse should instruct the adolescent to take a deep breath, place the lips around the mouthpiece, and then blow into the mouthpiece as hard and fast as possible. B. Values in the green zone represent 80% to 100% of the child's personal best; therefore, this does not warrant calling the provider. C. Slowly exhaling over a 10-second interval is an incorrect method of using the PEFM.
A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing
Correct Answer: D. Cover the oximetry sensor with clothing The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading. Incorrect Answers: A. The nurse should move the sensor to a new site every 4 to 8 hours. The pulse oximetry sensor should not remain in a single location for an extended period of time because of the risk of tissue necrosis. B. The pulse oximetry sensor should be placed around the infant's hand or foot to obtain an accurate reading. C. The pulse oximeter uses a sensor to measure oxygen in the infant's hemoglobin. Conduction gel would interfere with the reading because it would not allow the sensor to attach to the skin.
A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? A. Place the infant in a knee-chest position B. Initiate a fluid restriction C. Provide oxygen by nasal cannula D. Administer acetaminophen
Correct Answer: A. Place the infant in a knee-chest position The nurse should place the infant in a knee-chest position during a hypercyanotic episode. This position reduces the return of desaturated blood from the legs through the venous system and promotes the diversion of blood into the pulmonary artery. Incorrect Answers: B. The nurse should provide IV fluids as needed to treat the hypercyanotic episode. C. The nurse should apply a face mask to the infant and deliver 100% oxygen to treat the hypercyanotic episode. D. The nurse should expect to administer morphine to treat the hypercyanotic episode.
A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? A. Administer diphenhydramine B. Assess for laryngeal edema C. Initiate hourly urine output monitoring D. Give epinephrine IV push
Correct Answer: B. Assess for laryngeal edema The greatest risk to this child is bronchoconstriction due to an anaphylactic reaction to penicillin. Therefore, the first action the nurse should take is to assess the child for laryngeal edema and implement interventions to maintain a patent airway. Incorrect Answers: A. The nurse should administer an antihistamine such as diphenhydramine to treat the anaphylactic reaction to penicillin. However, there is another action the nurse should take first. C. The nurse should frequently monitor the child's urine output to determine the effects of the anaphylactic reaction. However, there is another action the nurse should take first. D. The nurse should administer epinephrine to treat the anaphylactic reaction to penicillin. However, there is another action the nurse should take first.
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk
Correct Answer: C. Administer an antifungal medication after feedings The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis. Incorrect Answers: A. The nurse should rinse the infant's mouth with water after feedings and prior to the application of antifungal medication. B. The nurse should identify that oral candidiasis is an adverse effect of antibiotic therapy. The nurse should implement measures to treat the candidiasis rather than discontinue treatment for the respiratory infection. D. The nurse should identify the need to treat both the infant and the mother for candidiasis simultaneously rather than discontinuing breastfeeding`.
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
Correct Answer: D. RBC 6.8 million/uL A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Incorrect Answers: A. A platelet count of 20,000/mm^3 is below the expected range. A child who has tetralogy of Fallot will not have a decreased platelet count. B. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has tetralogy of Fallot will not have neutropenia. C. This hormone level is above the expected reference range. A child who has tetralogy of Fallot will not have changes in thyroid function levels.
A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." E. "My child will have joint stiffness primarily at the end of the day."
Correct Answers: A. "My child will likely be irritable for the next few weeks." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. A child who has Kawasaki disease receives high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. Also, the temperature of this child who has Kawasaki disease should be recorded until she has been afebrile for several days. Incorrect Answers: B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and usually occurs between the second and third week. There is no need to report this manifestation to the child's provider. E. A child who has Kawasaki disease will likely have joint stiffness and arthritis-related symptoms for several weeks. The joint stiffness is typically worse during cold weather and in the morning.
A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry
Correct Answer: A. Provide a high-fat diet for the toddler Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat. Incorrect Answers: B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's daily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.
A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output
Correct Answer: A. Tell the guardian that a repeat dose of medication should not be given The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity. Incorrect Answers: B. The nurse should verify the prescribed digoxin regimen and the accuracy of home administration. However, there is another action the nurse should take first. C. The nurse should attempt to identify possible causes of the infant's vomiting. However, there is another action the nurse should take first. D. The nurse should determine if the infant's urinary output is adequate to evaluate the effectiveness of the digoxin in managing the infant's heart failure. However, there is another action the nurse should take first.
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent ductus arteriosus
Correct Answer: A. Transposition of the great arteries An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. Incorrect Answers: B. An infant who has a ventricular septal defect (a hole in the septal wall between the ventricles) can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for systemic circulation. C. An infant who has coarctation of the aorta (constricted segment of the aorta that obstructs blood flow to the body) is unlikely to have cyanosis. Even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation.
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents B. Use the FACES scale C. Use the numeric rating scale D. Check the child's temperature
Correct Answer: B. Use the FACES scale Pain is a subjective experience, even for a 3-year-old child. The FACES scale can be used to determine the presence of pain in children as young as 3 years of age. Incorrect Answers: A. Asking the parents is not appropriate, as pain is considered a personal experience. C. The numeric rating scale is appropriate for children who are 5 years of age or older. D. The child's temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, they are not reliable because pain is a subjective manifestation.
A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse
Correct Answer: C. The child is drooling When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction. Incorrect Answers: A. A finding of sallow skin is an expected finding for a child who is ill. Therefore, there is another finding that is the nurse's priority. B. An elevated temperature is an expected finding for a child who has influenza. Therefore, there is another finding that is the nurse's priority. D. A report of a hoarse voice is an expected finding for a child who has a sore throat. Therefore, there is another finding that is the nurse's priority.
A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min
Correct Answer: C. BP 86/40 mmHg A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider. Incorrect Answers: A. This temperature is within the expected reference range for a 6-month-old infant. B. This apical pulse level is within the expected reference range for a 6-month-old infant. D. This respiratory rate is within the expected reference range for a 6-month-old infant.
A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy B. Give the child a thorough explanation before providing care C. Encourage rooming-in D. Tell the child you will help fix her
Correct Answer: C. Encourage rooming-in Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope with an unfamiliar environment. Incorrect Answers: A. Toddlers are not as concerned about privacy as school-age children and adolescents. These children prefer to be with someone during procedures. B. A nurse should provide short, simple explanations for a toddler. A long explanation might cause the child's anxiety to increase. D. When speaking to a toddler, the nurse should refrain from using the word "fix" because the toddler may assume she is broken. Instead, the nurse should say, "I will help make you feel better."
A nurse is providing preoperative education for an 8-year-old child prior to cardiac surgery. Which of the following actions should the nurse take? A. Provide education for the child immediately before the surgery. B. Plan a teaching session that will last no longer than 60 min. C. Use a doll with tubes and an incision to explain the surgery. D. Discuss methods to cover the scar once healing has occurred.
Correct Answer: C. Use a doll with tubes and an incision to explain the surgery. Play involving visual and interactive approaches is appropriate for a school-age child's level of understanding. Incorrect Answers: A. School-age children should have preoperative teaching up to 1 day before the procedure to allow the child time to process the information and form questions. B. Teaching sessions should last no longer than 20 minutes for a school-age child. D. Concerns about changes to body image and the presence of a scar are important to adolescents rather than school-age children.
A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia
Correct Answer: C. Vomiting The nurse should identify that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately. Incorrect Answers: A. Irritability is not a manifestation of digoxin toxicity. B. Diaphoresis is not a manifestation of digoxin toxicity. D. Bradycardia, not tachycardia, is a manifestation of digoxin toxicity.
A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child
Correct Answer: D. Administer an antipyretic to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks
Correct Answer: D. Building towers with blocks Building towers with blocks is an appropriate activity for a 2-year-old child. and promotes fine-motor development. Also, knocking blocks down provides a means of dealing with the stress of hospitalization. Incorrect Answers: A. Most 2-year-old children do not have the coordination abilities to cut with scissors. This activity is appropriate for a 3-year-old child. B. The ability to draw stick figures is an appropriate activity for a 4-year-old child. A 2-year-old child will draw vertical lines and make circular strokes. C. Riding a tricycle is an appropriate activity for a 3-year-old child. Most 2-year-old children do not have the strength or the gross motor ability to ride a tricycle.
A nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions
Correct Answer: D. Inability to clear secretions The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway; the nurse must act in a manner that ensures transportation of oxygen to the body's cells. Incorrect Answers: A. Blood streaking of the sputum is a common finding in children who have cystic fibrosis and a pulmonary infection; therefore, this is not the nurse's priority. B. Children who have cystic fibrosis might have dry mucous membranes due to malabsorption of sodium and chloride, which results in dehydration; this is not the nurse's priority. C. Constipation is common in children who have cystic fibrosis because of malabsorption of sodium and chloride, resulting in dehydration; this is not the nurse's priority.
A nurse is teaching a group of parents and guardians about otitis media. Which of the following should the nurse identify as a risk factor for this illness? A. Summer months B. Breastfeeding C. Ages 7 to 10 years D. Passive smoking
Correct Answer: D. Passive smoking The nurse should identify passive smoking as a risk factor for otitis media. Exposure to secondhand smoke promotes the attachment of pathogens to the middle ear, extends the inflammatory response, and impairs drainage through the Eustachian tube. Each of these effects increases the risk for development of otitis media. Incorrect Answers: A. The nurse should identify winter and spring months as risk factors for otitis media. Respiratory infections are common during these months, and otitis media commonly occurs after this type of infection. B. The nurse should identify bottle-feeding as a risk factor for otitis media. The slanted position of the infant during bottle-feeding increases the risk of formula entering into the Eustachian tube, which raises the risk for otitis media. C. The nurse should identify ages 6 years and younger as a risk factor for otitis media. Otitis media is most common during the first 2 to 3 years of life and at ages 4 to 6 years when the child starts going to school.
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min
Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress. Incorrect Answer: A. The nurse should plan to provide the infant with feedings every 3 hours. This frequency allows the infant to get adequate rest between feedings while keeping the volume of feeding at a tolerable level.
