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 A
Explanation
Choice A rationale:
After a tonic-clonic seizure, it's common for the person to inadvertently bite their tongue, cheeks, or lips during the convulsive movements. Checking the mouth for any signs of bleeding or injuries is essential to ensure the person's safety and provide appropriate care.
Choice B rationale:
Placing the child's head in a hyperextended position is not recommended after a seizure. In fact, it's important to keep the person's head and neck in a neutral position to prevent potential injury. Hyperextending the neck could lead to strain or other complications.
Choice C rationale:
Giving the child a drink of water immediately after a seizure is not necessary and might be unsafe. The child may still be disoriented or have difficulty swallowing immediately after the seizure. It's best to ensure the child's safety and monitor their condition before offering any fluids.
Choice D rationale:
Administering naloxone intramuscularly is not indicated for a tonic-clonic seizure. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Seizures have a different underlying cause, and administering naloxone would not be effective or appropriate in this context.
Correct Answer is C
Explanation
Choice A rationale:
Perfectionistic behavior is not typically considered a behavioral finding indicative of sexual abuse in a school-age child. Perfectionism may be related to personality traits, family dynamics, or individual tendencies, but it is not a specific behavioral marker for sexual abuse.
Choice B rationale:
Manipulative behavior is not a specific indicator of sexual abuse in a school-age child. Children can display manipulative behavior for various reasons, including seeking attention or attempting to control situations. While behavioral changes can occur in response to trauma, manipulative behavior alone does not necessarily point to sexual abuse.
Choice C rationale:
Withdrawn behavior is a possible indication of sexual abuse in a school-age child. Sexual abuse can cause emotional and psychological distress in children, leading them to withdraw from social interactions. They might become isolated, exhibit changes in their usual behavior, and show decreased interest in activities they previously enjoyed.
Choice D rationale:
Destructive behavior is not a prominent behavioral finding associated specifically with sexual abuse in a school-age child. Destructive behaviors can arise from a range of factors, including emotional difficulties, behavioral disorders, or reactions to stressors. While trauma like sexual abuse can influence behavior, it's not a defining characteristic of sexual abuse in isolation.
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