Chapter 17

Ventricular Septal Defect Answers

Answers

1. Correct answer: c. Respiratory rate of 56 breaths/min with intercostal retractions.  A respiratory rate of 56 breaths per minute with retractions and nasal flaring suggests increased work of breathing, which may indicate worsening heart failure due to pulmonary congestion. This requires immediate follow-up. While a murmur (b) and low weight (a) are expected with VSD, they do not require urgent intervention. Oxygen saturation of 96% (d) is within the normal range.

2. Correct answer: a. Imbalanced nutrition: Less than body requirements related to increased energy expenditure. Infants with VSD experience increased metabolic demand due to poor cardiac output and increased work of breathing, leading to poor feeding and inadequate weight gain. This is the priority because it affects growth and development. While ineffective airway clearance (b) and risk for infection (c) are concerns, ensuring adequate nutrition is more urgent.

3. Correct answer: b. Check Grace’s blood pressure and electrolyte levels. Furosemide is a loop diuretic that reduces pulmonary congestion and preload, but it can cause hypotension and electrolyte imbalances (especially hypokalemia). Checking blood pressure and electrolytes helps prevent complications. Simply documenting (a) is not enough, and offering more fluids (d) without assessment could worsen her condition.

4. Correct answer: b. Hold the medication if Grace’s blood pressure is significantly lower than baseline. Enalapril is an ACE inhibitor used to reduce afterload and improve cardiac output, but it can cause hypotension. If her BP is significantly lower than baseline, the nurse should hold the dose and notify the provider. Administering it without checking vitals (a) is unsafe. Mixing it with milk (c) could alter absorption. Medication should be documented immediately after administration, not afterward (d).

5. Correct answer: a. Grace should be positioned upright for feedings and given small, frequent meals. Babies with VSD tire easily while feeding, so frequent, small-volume feedings and an upright position help reduce fatigue and improve intake. Limiting activity (b) is not appropriate for infants. Many small VSDs close over time (c), but not in just a few weeks. While some defects require surgery, not all do (d).

6. Correct answer: b. “If Grace’s breathing becomes labored, we will wait a few days to see if it improves.” Labored breathing is a sign of worsening heart failure and requires immediate medical attention. Delaying care can lead to pulmonary congestion and respiratory distress. The other statements reflect correct understanding, including monitoring weight/feeding (c), recognizing heart failure signs (a), and following up with cardiology (d).

Please find answers to the Learning Activity interactive elements within the element.