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Sandie95 Sandie95
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6 years ago
A pediatric nurse palpates a 2-year-old child's liver at 4 cm below the right costal margin. Which actions by the nurse are appropriate? (Select all that apply.)
 
  A.
  Assess work of breathing.
  B.
  Auscultate lung sounds.
  C.
  Calculate child's intake and output.
  D.
  Determine last bowel movement.
  E.
  Listen for heart murmur.
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#1
6 years ago
ANS: A, B, C, D
An enlarged liver in a child can be indicative of heart failure or fluid overload from congenital heart defects. Assessing for respiratory distress, listening to heart and lung sounds, and calculating I&O will all give information related to cardiac function. Bowel movements are not related.
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