# A 6-month-old infant with ventricular septal defect (VSD) is seen in the clinic for follow-up and exhibits poor weight gain and tachypnea. Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541945 > language: ko > subject: Child Health ## 문제 A 6-month-old infant with ventricular septal defect (VSD) is seen in the clinic for follow-up and exhibits poor weight gain and tachypnea. Which nursing intervention should be the highest priority? ## 보기 1. Encourage increased fluid intake 2. Administer prescribed furosemide to reduce pulmonary congestion **✔ 정답** 3. Provide high-calorie formula every 2 hours to promote weight gain 4. Administer oxygen therapy at 6 L/min via nasal cannula **정답: 2** ## 해설 Administering prescribed furosemide reduces pulmonary congestion by promoting diuresis, which directly addresses the tachypnea and poor weight gain associated with heart failure in VSD. This is the highest priority nursing intervention to stabilize the infant's condition. ## 심화 해설 Understanding the Priority: Why Furosemide Comes First The infant's clinical picture of poor weight gain and tachypnea in the setting of a ventricular septal defect (VSD) points directly to heart failure (HF). A VSD creates a left-to-right shunt, forcing blood from the high-pressure left ventricle into the right ventricle and pulmonary artery. This leads to pulmonary overcirculation and congestion. The work of breathing increases (tachypnea), and the metabolic demand of labored breathing, combined with the body's attempt to compensate for reduced cardiac efficiency, burns calories at a rate that easily outpaces intake, causing poor weight gain. The highest priority intervention is to address the root physiological problem: the excessive pulmonary blood flow that is driving the symptoms. Administering the prescribed furosemide directly reduces intravascular volume and decreases venous return to the right heart. This action lowers the preload, which in turn reduces the volume of blood shunted into the pulmonary circuit. By decongesting the lungs, the work of breathing decreases, and the infant's metabolic demand can stabilize, creating a physiological environment where nutritional interventions can actually succeed. Analyzing the Other Options - Option 1: Encourage increased fluid intake. This is contraindicated. In a state of pulmonary congestion from a left-to-right shunt, increasing total body fluid volume would worsen the congestion, increase the work of breathing, and further tax the failing heart. Fluid management in VSD-related heart failure is often restrictive, not liberal. - Option 3: Provide high-calorie formula every 2 hours to promote weight gain. While optimizing nutrition is a critical long-term goal for these infants, it is not the immediate priority. Feeding is a significant stressor for a tachypneic infant in heart failure; they tire easily and risk aspiration. Attempting to aggressively feed a child with uncorrected pulmonary congestion is ineffective and potentially dangerous. The respiratory status must be stabilized first to lower metabolic demand and make safe, effective feeding possible. - Option 4: Administer oxygen therapy at 6 L/min via nasal cannula. This is a dangerous intervention for an infant with a VSD. The primary cause of the tachypnea is not a pulmonary diffusion defect but rather excessive blood flow. Administering supplemental oxygen acts as a pulmonary vasodilator. Decreasing pulmonary vascular resistance will actually *increase* the magnitude of the left-to-right shunt, worsening the pulmonary edema and heart failure symptoms. Oxygen therapy is used with extreme caution in this population and is not a first-line treatment for this clinical presentation. The systematic review on optimizing hemostasis in neonatal and infant cardiac surgery underscores the profound physiological vulnerability of this population, particularly the challenges of managing hemodynamics and fluid shifts. While its focus is on the operative setting, the principle of meticulous hemodynamic management is directly transferable to the medical management of a VSD. The core issue is a volume overload state in the pulmonary circuit, and the priority is to manage that volume with diuresis, not to add more fluid or inadvertently increase the shunt with oxygen. ## 임상 시나리오 Clinical Management of VSD with Heart Failure Symptoms Pathophysiology Overview A ventricular septal defect (VSD) allows a left-to-right shunt, increasing pulmonary blood flow. This leads to pulmonary overcirculation, interstitial edema, and reduced lung compliance. The infant compensates with tachypnea, which increases metabolic demand and caloric expenditure, resulting in poor weight gain. The primary goal is to interrupt this cycle by reducing pulmonary congestion. Immediate Nursing Priorities - **Administer Diuretics:** Furosemide is the first-line intervention to reduce preload and pulmonary venous congestion. This decreases the work of breathing and stabilizes the infant for further interventions. - **Monitor Fluid Status:** Strict intake and output, daily weights, and assessment for signs of dehydration or electrolyte imbalance (especially hypokalemia) are essential when using loop diuretics. - **Respiratory Assessment:** Continuously monitor respiratory rate, effort, and oxygen saturation. Position the infant in a semi-Fowler’s position to facilitate lung expansion. Nutritional and Supportive Care - **Caloric Optimization:** Once respiratory status is stabilized, provide high-calorie (24-30 kcal/oz) formula. Small, frequent feedings every 2-3 hours reduce gastric distension and energy expenditure during feeding. - **Fluid Management:** Avoid excessive fluid intake. Fluid restriction may be prescribed to prevent further volume overload. Never encourage increased fluids in a congested state. - **Oxygen Therapy:** Administer oxygen only if hypoxemia is present. High flow rates (e.g., 6 L/min) are rarely indicated and can cause discomfort, mucosal drying, and increased metabolic stress in infants. Family Education and Discharge Planning - **Medication Teaching:** Educate caregivers on the purpose, dose, and side effects of furosemide, including the need for potassium monitoring and signs of dehydration. - **Feeding Techniques:** Demonstrate paced bottle-feeding and the use of a high-calorie formula. Teach caregivers to recognize feeding fatigue and early satiety. - **Warning Signs:** Instruct caregivers to seek immediate care for increased work of breathing, periorbital edema, decreased urine output, or failure to gain weight. ## 핵심 개념 - **Ventricular Septal Defect (VSD)** — A congenital heart defect characterized by an opening in the septum between the ventricles, causing a left-to-right shunt that leads to increased pulmonary blood flow and heart failure symptoms. - **Furosemide** — A loop diuretic used to reduce preload and intravascular volume, thereby decreasing pulmonary congestion and the work of breathing in heart failure. - **Left-to-right shunt** — A pattern of blood flow in which oxygenated blood from the left heart recirculates into the right heart and pulmonary arteries, leading to pulmonary overcirculation. - **Preload** — The degree of myocardial stretch at the end of diastole, determined by the volume of blood returning to the heart; reducing preload helps manage heart failure symptoms. - **Tachypnea** — An abnormally rapid respiratory rate, often a compensatory mechanism or a sign of pulmonary congestion in infants with heart failure. ## 같은 주제 문제 - [A 2-year-old toddler with a history of ventricular septal defect (VSD) repair is brought t…](https://mymerci.kr/pages/nclex_q.php?qn_id=541942) - [A 6-month-old infant with tetralogy of Fallot is being prepared for surgical repair. 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