A child with a heart defect has been prescribed a maintenance dose of Lanoxin elixir at 0.07 mg/kg/day, divided into two doses.
The child weighs 19 pounds.
What is the maximum dose of medication the nurse should administer in each dose? T 0.3 mg.
Answer and explanation
The correct answer is Choice B, Choice C, Choice D.
Choice A rationale
A large bruise on the forehead of a 2-year-old could occur from accidental falls, which are common at this developmental stage due to increased mobility and decreased coordination. It does not necessarily suggest abuse unless accompanied by other suspicious findings.
Choice B rationale
Circular abrasions around the wrists are highly indicative of physical abuse as they suggest binding injuries. Restraining a child is neither acceptable nor normal, and such findings must be reported for further investigation by child protective services.
Choice C rationale
A burn on the palm of a 10-year-old’s hand raises concerns for abuse as accidental burns usually occur on accessible areas like arms or legs, not the palm. This pattern could indicate intentional infliction, requiring mandatory reporting to authorities.
Choice D rationale
Splash burns on the front torso in a 6-year-old are suspicious if inconsistent with the child’s developmental abilities or history provided by caregivers. Intentional scald burns often follow specific patterns, like splash marks, and must be reported for investigation.

Choice A rationale

Administering oral glucose for comfort can provide analgesia and soothe a newborn experiencing withdrawal symptoms, which often include irritability and crying. The hyperglycemic solution activates sweet taste receptors and provides a calming effect. It does not alter the newborn's withdrawal process but aids in temporary relief from discomfort caused by neonatal abstinence syndrome. Sweet solutions are commonly used for procedural pain management in neonates.

Choice B rationale

Observing the newborn in a well-lit nursery is inappropriate for managing withdrawal symptoms. Bright lights can overstimulate the newborn and exacerbate symptoms such as irritability and crying. Neonates exposed to heroin in utero often require a low-stimulation environment to prevent sensory overload, as their central nervous system is already compromised by drug exposure. Excessive stimulation can worsen withdrawal effects, increasing stress for the infant.

Choice C rationale

Maintaining a low-stimulation environment is critical for newborns experiencing withdrawal. These infants benefit from dim lighting, minimal noise, and reduced handling, as their central nervous system is hypersensitive. High stimulation may intensify symptoms like tremors and irritability. A controlled, soothing environment helps stabilize the newborn's condition by promoting better neurological regulation and decreasing withdrawal-related distress.

Choice D rationale

Offering the newborn a pacifier helps to satisfy non-nutritive sucking needs, which are often heightened in neonates with withdrawal symptoms. The act of sucking can comfort the infant and reduce irritability associated with neonatal abstinence syndrome. Non-nutritive sucking is a self-soothing behavior that has been proven to decrease stress responses and stabilize physiological parameters in affected infants.

Choice E rationale

Feeding the infant half-strength formula is inappropriate as it can lead to nutritional deficiencies, which are harmful to a newborn already at risk due to prenatal drug exposure. Newborns require adequate caloric intake to support growth and recovery. Half-strength formula lacks sufficient nutrients necessary for healthy weight gain and organ development. Full-strength, nutrient-rich feeding is advised for optimal neonatal care.

Choice F rationale

Swaddling the newborn with legs flexed mimics the intrauterine environment and provides a sense of security to a neonate undergoing withdrawal symptoms. This method reduces sensory stimulation and decreases distress, helping stabilize the infant's condition. Swaddling promotes calming and decreases excessive movements such as tremors, which are characteristic of neonatal abstinence syndrome. It is a widely accepted comfort measure.

Choice A rationale

Difficulty feeding in infants can result from fatigue caused by inadequate oxygen delivery to tissues due to heart failure. Feeding is a demanding activity that requires energy and coordination, making it an early symptom of cardiac compromise in pediatric patients.

Choice B rationale

Wheezes or rales are caused by pulmonary congestion or edema, which occur in heart failure due to increased pulmonary venous pressure. This congestion results in fluid accumulation in the alveoli, leading to abnormal breath sounds. These findings require prompt evaluation.

Choice C rationale

Edema in the feet and legs results from systemic venous congestion caused by right-sided heart failure. Increased hydrostatic pressure in peripheral veins leads to fluid leakage into interstitial spaces, causing swelling, especially in dependent areas.

Choice D rationale

Tachypnea occurs as a compensatory mechanism in heart failure. Poor cardiac output reduces oxygen delivery, triggering the respiratory center to increase the breathing rate to improve oxygen uptake and delivery. It is an early sign of cardiopulmonary compromise in children.