🌻 Congestive heart failure — Correct
🌻 The infant has multiple findings consistent with pediatric heart failure, including tachycardia, tachypnea, poor feeding, failure to thrive, diaphoresis, and peripheral edema.
🌻 Crackles in all lung fields and increased pulmonary vascular markings on chest x-ray indicate pulmonary congestion.
🌻 The infant’s oxygen saturation of 90%, nasal flaring, and moderate retractions show significant respiratory compromise.
🌻 Periorbital and pedal edema suggest systemic fluid retention associated with impaired cardiac function.
🌻 The chest x-ray finding of left ventricular hypertrophy further supports a cardiac cause.
🌻 Decreased urine output, with no wet diaper for about 10 hours, suggests reduced renal perfusion and worsening fluid imbalance.
🌻 Poor feeding and diaphoresis during feeding are classic manifestations of heart failure in young infants because feeding increases cardiac workload.
🌻 Therefore, congestive heart failure is the condition that best explains the overall clinical picture.
🌻 Anticipate a prescription for digoxin — Correct
🌻 Digoxin can be prescribed in selected infants with heart failure to improve myocardial contractility.
🌻 By increasing the force of cardiac contraction, digoxin can improve cardiac output and tissue perfusion.
🌻 Improved cardiac output can reduce manifestations such as tachycardia, feeding intolerance, fatigue, and poor weight gain.
🌻 The nurse should assess the infant’s apical pulse for a full minute before administration and follow pediatric hold parameters.
🌻 Digoxin has a narrow therapeutic range, so monitoring for toxicity is important.
🌻 Toxicity can manifest as vomiting, poor feeding, bradycardia, dysrhythmias, or lethargy.
🌻 Electrolytes, especially potassium, should also be monitored because abnormalities can increase digoxin toxicity risk.
🌻 Therefore, anticipating digoxin is appropriate for management of this infant’s heart failure.
🌻 Elevate the head of the bed to 45° — Correct
🌻 Elevating the head of the bed promotes lung expansion and decreases the work of breathing.
🌻 The infant is already experiencing tachypnea, retractions, nasal flaring, crackles, and low oxygen saturation.
🌻 Upright positioning can improve ventilation and reduce the sensation of respiratory distress.
🌻 It also helps decrease venous return to the heart slightly, which may reduce pulmonary congestion.
🌻 Positioning is a noninvasive intervention that can be implemented immediately while additional treatment is initiated.
🌻 The nurse should continue monitoring oxygen saturation and respiratory effort while maintaining the infant in a position that supports breathing.
🌻 Feeding may also need modification because the infant becomes tachypneic and fatigued with feeds.
🌻 Therefore, head-of-bed elevation is an appropriate supportive intervention.
🌻 Intake and output — Correct
🌻 Monitoring intake and output is essential because this infant demonstrates both fluid retention and decreased renal perfusion.
🌻 The infant has edema but also slightly dry mucous membranes, decreased skin turgor, and a dry diaper for approximately 10 hours.
🌻 These mixed findings can occur when fluid is retained in tissues while effective circulating volume remains reduced.
🌻 Urine output is an important indicator of renal perfusion and cardiac output.
🌻 The nurse should carefully track oral or enteral intake, urine output, and any fluid administered intravenously.
🌻 Daily weights may also help evaluate changes in fluid status.
🌻 Improvement should include adequate urine production and reduced edema.
🌻 Therefore, intake and output are important parameters for assessing treatment progress.
🌻 Respiratory status — Correct
🌻 The infant’s respiratory findings are among the most concerning manifestations of heart failure.
🌻 Current abnormalities include a respiratory rate of 72/min, retractions, nasal flaring, crackles, and oxygen saturation of 90%.
🌻 Pulmonary congestion from left-sided cardiac dysfunction can significantly impair oxygenation.
🌻 The nurse should monitor respiratory rate, work of breathing, lung sounds, oxygen saturation, and signs of fatigue.
🌻 Improving respiratory status would indicate decreasing pulmonary fluid congestion and better cardiac function.
🌻 Worsening crackles, cyanosis, increasing oxygen needs, or decreased responsiveness would indicate deterioration.
🌻 Respiratory monitoring is especially important during feedings because infants with heart failure can become rapidly fatigued and hypoxemic.
🌻 Therefore, respiratory status is a key indicator of whether the infant is responding to treatment.
❌ Why the other choices do not fit
RSV bronchiolitis would more commonly be associated with viral symptoms such as congestion, wheezing, or known infectious exposure rather than left ventricular hypertrophy, bounding upper-extremity pulses, edema, and pulmonary vascular congestion. Cystic fibrosis is more strongly associated with recurrent respiratory infections, thick secretions, poor growth, and steatorrhea. Pyloric stenosis typically causes projectile nonbilious vomiting, dehydration, and visible peristaltic waves rather than pulmonary crackles and edema.
