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HESI RN EXIT CASE STUDY: CONGENITAL HEART DISEASE 1. Which clinical manifestations would the nurse expect to assess in an infant diagnosed with ventricular septal defect (VSD) ANS: Tachypnea and grunting with intercostal and subcostal retractions 2. The nurse understands that a child is experiencing heart failure when which symptoms are found ANS: -Cool extremities. -Peripheral edema. -Nasal Flaring. 3. Which statement by Joan supports Timmy's diagnosis of CHF ANS: "Timmy never seems to get full even when I breastfeed him for a long time." 4. What should the nurse include when teaching Timmy's parents about post-procedure care ANS: Explain that they will need to hold Timmy in the prone position after the procedure. 5. Which action should the nurse implement ANS: Notify the cardiologist and do not allow Thomas to sign the permit. 6. Which nursing intervention must be included in Timmy's plan of care related to this diagnosis ANS: Assess the infant's peripheral pulses and capillary refill time. 7. Which response is most important for the nurse to educate the parents about feeding ANS: "Your son will be able to suck more easily and will not be so tired from feeding." 8. Which member of the perinatal care team will best be able to assist the nurse ANS: Certified Lactation Consultant (CLC). 9. Which measurement will be most useful to evaluate Timmy's response to each feeding technique ANS: SaO2 changes during feeding. 10. Which intervention should the nurse implement prior to administering the first dose of digoxin (Lanoxin) to Timmy
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