Pediatric ATI Practice Exam

Which of the following assessments should a nurse include for a patient with suspected congenital heart disease?

1. Blood glucose monitoring

2. Bowel sounds auscultation

3. Capillary refill time

4. Palpation of abdomen

The correct answer is: Capillary refill time

Capillary refill time is a critical assessment in patients with suspected congenital heart disease because it provides valuable information about peripheral perfusion and cardiac output. In children, a prolonged capillary refill time, typically greater than 2 seconds, can indicate issues with circulation that are often associated with cardiac dysfunction. This assessment helps the nurse evaluate the effectiveness of the heart's pumping ability and the adequacy of blood flow to the extremities. Assessing capillary refill time is particularly important in congenital heart disease, where structural anomalies can lead to changes in hemodynamics. Early identification of perfusion issues can lead to timely interventions to prevent complications, making this assessment a priority in a pediatric cardiac evaluation. While blood glucose monitoring, bowel sounds auscultation, and abdominal palpation may be relevant in other contexts or for different conditions, they do not provide specific insights into cardiac function or hemodynamics in the context of suspected congenital heart disease.