# A 3-month-old infant with congenital heart failure is admitted to the pediatric unit with worsening symptoms. The nurse notes increased work of breathing, poor feeding, and weight gain of 1.5 pounds over the past week. Which nursing action should the nurse prioritize first?

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## 문제

A 3-month-old infant with congenital heart failure is admitted to the pediatric unit with worsening symptoms. The nurse notes increased work of breathing, poor feeding, and weight gain of 1.5 pounds over the past week. Which nursing action should the nurse prioritize first?

## 보기

1. Administer prescribed furosemide (Lasix) as ordered **✔ 정답**
2. Obtain a chest X-ray to assess cardiac enlargement
3. Weigh the infant to establish baseline weight
4. Place the infant in high Fowler's position

**정답: 1**

## 해설

In heart failure exacerbation, fluid overload (2 lb weight gain) is life-threatening. Administering furosemide reduces preload and improves cardiac output as the priority. Other options (chest X-ray, weighing, positioning) are important but do not address the immediate fluid overload.

## 심화 해설

Clinical Reasoning and Priority Setting in Pediatric Heart Failure

The nurse must recognize that the infant's presentation—increased work of breathing, poor feeding, and a rapid weight gain of 1.5 pounds (0.68 kg) in one week—is a classic manifestation of acute fluid volume overload. In the context of congenital heart failure, the failing myocardium cannot effectively pump blood forward, leading to pulmonary and systemic venous congestion. The weight gain here is not true somatic growth but rather a sensitive indicator of fluid retention, as 1 kg of weight gain roughly equates to 1 liter of fluid accumulation. This fluid overload directly exacerbates respiratory distress by causing pulmonary edema, which is the immediate threat to the infant's oxygenation and ventilation.

While all the listed options are relevant aspects of care, the nurse must prioritize actions using the ABC (Airway, Breathing, Circulation) framework. The infant's increased work of breathing signals that gas exchange is already compromised. The most immediate and effective physiological intervention to reduce preload and alleviate pulmonary congestion is the administration of a rapid-acting loop diuretic. Furosemide (Lasix) works by inhibiting sodium and chloride reabsorption in the thick ascending limb of the loop of Henle, producing a potent diuretic effect that quickly mobilizes excess fluid from the pulmonary interstitium back into the vascular space for renal excretion [1]. This directly addresses the "Breathing" component of the ABCs by improving lung compliance and reducing the work of breathing.

The pathophysiology of fluid overload in infants with cardiac disease is compounded by renal immaturity and potential endothelial glycocalyx damage, which can make them exquisitely sensitive to even small volume shifts [1]. In the pediatric cardiac intensive care setting, managing this fluid overload with diuretics is a cornerstone of stabilization, as persistent congestion further impairs cardiac output and can lead to multi-organ dysfunction [1,2]. Therefore, administering the prescribed diuretic is the priority nursing action because it has the most direct and rapid impact on correcting the underlying cause of the respiratory distress.

The other options are important but are secondary to the immediate physiological intervention. Placing the infant in a high Fowler's position (Option 4) can help with work of breathing by using gravity to lower the diaphragm and reduce pressure on the thoracic cavity, but it does not remove the excess fluid causing the problem. Obtaining a chest X-ray (Option 2) is a diagnostic measure that will confirm cardiac enlargement and pulmonary edema but offers no therapeutic benefit to the infant in acute distress. Weighing the infant (Option 3) is a critical nursing function for accurate intake and output monitoring and medication dosing, but establishing a baseline weight does not take precedence over treating the acute respiratory compromise that the weight gain represents. The nurse already has a key clinical data point—the rapid weight gain—which, when paired with the respiratory assessment, provides sufficient evidence to act on the diuretic order without delay [2].References (research sources)

- [1]Advancements in research on fluid overload in preterm infants-a narrative review.Research articleLiu X, Deng S, Chen S, Wan L, Dong W, Kang L. (2025) · DOI: 10.3389/fped.2025.1691874

- [2]Retrospective Evaluation of Dosing Effects of Bumetanide Continuous Infusions in the Pediatric Cardiac Intensive Care Unit.Research articleNarasimhulu SS, Williams B, Kelly B, Lopez-Colon D, Peek G, Jacobs JP, Sullivan K, Brock MA, Hernandez-Rivera J, Vasquez-Colon Z, Wang W, Dibert T, Bleiweis MS, Philip J. (2025) · DOI: 10.5863/jppt-24-00050

## 임상 시나리오

Clinical Guide: Prioritizing Diuretic Therapy in Pediatric Heart Failure

For an infant with congenital heart failure presenting with acute respiratory distress and rapid weight gain, the immediate priority is to reduce fluid volume overload using a loop diuretic such as furosemide. This directly targets the pulmonary edema compromising the airway and breathing, aligning with the ABC priority framework. The following steps outline the critical nursing actions and rationale for safe administration and monitoring.

Step 1: Rapid Assessment and Recognition

Recognize that a weight gain of 1.5 pounds (0.68 kg) in one week in an infant with heart failure is a sensitive indicator of fluid retention, not somatic growth. This volume overload manifests as increased work of breathing, tachypnea, and poor feeding due to pulmonary congestion. Immediately assess vital signs, oxygen saturation, lung sounds for crackles, and signs of respiratory fatigue.

Step 2: Administer Furosemide as the First-Line Intervention

Administer the prescribed dose of intravenous furosemide without delay. The IV route provides the fastest onset of action, typically within 5 minutes, to mobilize fluid from the pulmonary interstitium. This reduces preload and quickly alleviates dyspnea. Ensure the dose is verified according to the infant's weight and institutional protocol.

Step 3: Monitor Therapeutic Response and Electrolytes

Closely monitor urine output, expecting a significant increase within 30 minutes of IV administration. Document strict intake and output. Monitor serum potassium levels before and after administration, as loop diuretics cause potassium wasting, increasing the risk of hypokalemia and cardiac dysrhythmias. Observe for signs of dehydration such as dry mucous membranes or sunken fontanelles.

Step 4: Support Respiratory Status Concurrently

While the diuretic takes effect, position the infant in a semi-upright or high Fowler's position to facilitate lung expansion and reduce the work of breathing. Administer supplemental oxygen as ordered to maintain SpO2 within the target range. Prepare for potential escalation, such as non-invasive ventilation, if respiratory distress does not improve.

Step 5: Obtain Baseline and Follow-Up Diagnostics

After stabilizing the infant's respiratory status, obtain a daily weight using the same scale to establish a new baseline and track fluid loss. A chest X-ray and other diagnostics like echocardiography or BNP levels can be performed to assess cardiac size and function, but these should not delay the diuretic administration.

## 핵심 개념

- **Furosemide** — A rapid-acting loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, used to quickly reduce fluid volume overload and pulmonary congestion.
- **Fluid Volume Overload** — A state of excess total body fluid, often indicated by rapid weight gain (1 kg ≈ 1 L fluid), leading to symptoms like pulmonary edema and respiratory distress in heart failure.
- **ABC Framework** — A priority-setting model (Airway, Breathing, Circulation) used in nursing to identify and manage the most immediate life-threatening conditions first.
- **Preload** — The degree of myocardial stretch at the end of diastole, determined by the volume of blood returning to the heart; reducing preload with diuretics decreases pulmonary congestion.
- **Pulmonary Edema** — Accumulation of fluid in the lung interstitium and alveoli, impairing gas exchange and causing increased work of breathing, a common consequence of left-sided heart failure.

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