A nurse is assisting with the plan of care for an infant who has heart failure. Which of the following actions should the nurse recommend to include in the plan of care?
Ensure the infant bottle feeds for 45 min.
Administer digoxin for a pulse of 70/min.
Allow for frequent rest periods.
Maintain the infant in a supine position.
The Correct Answer is C
Choice A rationale:
Ensuring the infant bottle feeds for 45 minutes is not recommended for an infant with heart failure. Prolonged feeding sessions can lead to increased fatigue and stress on the infant's cardiovascular system, exacerbating the heart failure symptoms.
Choice B rationale:
Administering digoxin for a pulse of 70/min is not appropriate. Digoxin is commonly used in heart failure cases to improve cardiac contractility and reduce heart rate. However, giving digoxin solely based on the heart rate without considering other factors can lead to potential overdose and adverse effects.
Choice C rationale:
(Correct Choice) Allowing for frequent rest periods is crucial in the plan of care for an infant with heart failure. Infants with heart failure often experience fatigue and difficulty feeding due to compromised cardiac function. Allowing them to rest between activities helps conserve energy and supports their overall well-being.
Choice D rationale:
Maintaining the infant in a supine position is not the best choice for an infant with heart failure. While the supine position is recommended for safe sleep to reduce the risk of sudden infant death syndrome (SIDS), it may not be optimal for an infant with heart failure. An inclined position may be more suitable to alleviate potential respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
Correct Answer is C
Explanation
Choice A rationale:
Encouraging active range of motion of the extremity is not recommended during the first 12 to 24 hours after a sprained wrist. Early movement can potentially worsen the swelling and delay the healing process.
Choice B rationale:
Applying warm compresses to the extremity is not the best choice to minimize swelling in the initial 12 to 24 hours after a sprained wrist. Heat can actually increase blood flow and promote more swelling in the injured area.
Choice C rationale:
Elevating the extremity above the level of the heart is the correct choice for minimizing swelling in the first 12 to 24 hours after a sprained wrist. Elevating the injured area helps to reduce blood flow to the area, which in turn decreases swelling and promotes healing.
Choice D rationale:
Wrapping the extremity loosely with an elastic bandage might be beneficial for providing support, but it's not the primary intervention for minimizing swelling in the first 12 to 24 hours after a sprained wrist. Elevation is more effective for reducing swelling during this initial period.
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