Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
9. Which assessment finding should a nurse most expect in a newborn infant with a cyanotic heart defect?
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
9. Which assessment finding should a nurse most expect in a newborn infant with a cyanotic heart defect?
Test-Taking Tip
The key word in the stem of the question is "newborn." The correct response should take into account the infant's young age and the fact that the child has not suffered from congenital heart disease for an extended period of time.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because clubbing in fingers and toes will not be evident in an infant. This symptom develops over time and would be expected in an older child. Answer 2 is correct because the newborn with a cyanotic heart defect will most likely experience tachycardia as the heart attempts to improve oxygenation. Answer 3 is incorrect because polycythemia may not develop right away, while tachycardia is present at birth. Answer 4 is incorrect because distended neck veins are not always present in infants with cyanotic defects even if the infant is in congestive heart failure.
