A nurse is administering digoxin to an infant. The apical pulse is 88 bpm. What should the nurse do?
Administer half the dose.
Administer the dose.
Administer double the dose.
Hold the dose and notify the provider.
The Correct Answer is D
Choice A rationale
Administering half the dose is inappropriate and lacks a scientific basis unless ordered by the provider, as it would likely be sub-therapeutic and fail to achieve the desired effect of improving myocardial contractility and reducing heart rate. Digoxin administration should be all or none based on parameters.
Choice B rationale
The acceptable apical pulse rate for administering digoxin to an infant is typically above 90-110 beats per minute (bpm). An apical pulse of 88 bpm falls below this generally accepted cutoff, indicating potential drug toxicity or the therapeutic effect lowering the rate too much, necessitating withholding the dose.
Choice C rationale
Administering double the dose is a dangerous, unscientific action that would significantly increase the risk of digoxin toxicity, which can cause severe cardiac arrhythmias, gastrointestinal symptoms, and potential cardiac arrest, particularly in infants who are highly susceptible to small dose changes.
Choice D rationale
The normal heart rate for an infant is significantly higher than 88 bpm. Holding the dose and notifying the provider is the required action. Bradycardia in an infant receiving digoxin is the cardinal sign of potential toxicity or an excessively deep therapeutic effect, and the provider must assess the situation before further dosing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The expected urine output for an infant is 1-2 mL/kg/hr. For this 7.5 kg infant, the minimum expected output is (1 mL/kg/hr× 7.5 kg) × 12 hours = 90 mL. The actual output of 93 mL over 12 hours is just above the minimum of 90 mL, placing it within the normal, expected physiological range.
Choice B rationale
This choice is incorrect because the calculated minimum normal urine output for a 7.5 kg infant over 12 hours is 90 mL. The actual output of 93 mL exceeds this minimum threshold, confirming that the infant's renal excretion is adequate and within the lower bounds of the normal physiological range.
Correct Answer is B
Explanation
Choice A rationale
While dehydration can cause irritability and poor feeding, it typically manifests with depressed fontanels, not a bulging fontanel, which is a hallmark sign of increased intracranial pressure. Dehydration would also likely present with dry mucous membranes and decreased urine output, differentiating it from shunt issues.
Choice B rationale
The combination of irritability, vomiting, and a bulging fontanel are classic clinical indicators of increased intracranial pressure (ICP) in an infant. This constellation of signs strongly suggests that the ventricular shunt is obstructed or malfunctioning, preventing adequate cerebrospinal fluid drainage.
Choice C rationale
Normal shunt function maintains cerebrospinal fluid (CSF) flow, keeping the intracranial pressure within the normal range, preventing the pathological signs of obstruction. A normally functioning shunt would result in the resolution of or prevention of symptoms like a bulging fontanel, irritability, and vomiting.
Choice D rationale
Gastroenteritis, or infectious diarrhea, primarily presents with diarrhea, vomiting, and often fever. Although vomiting and irritability can occur, a bulging fontanel is highly specific to elevated intracranial pressure and is not a symptom typically associated with routine infectious gastroenteritis.
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