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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A history of frequent urinary tract infections (UTIs) is a sign of child maltreatment. It may indicate sexual abuse, which can introduce bacteria into the urinary tract.Sexual abuse may also cause genital or anal trauma, sexually transmitted infections, or pregnancy 1. UTIs are uncommon in children, especially in boys.The normal frequency of UTIs in children is around 1 in 10 girls and 1 in 30 boys by the age of 16 years

A. Warm the skin prior to probe placement. B. Reposition the probe every 2 hr. C. Tape the wire to the palm of the hand. D. Apply the sensor to the index fingernail.

Correct Answer is B

Explanation

Answer: B. Reposition the probe every 2 hours.

Rationale:

A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

The nurse should also choose a clean and dry site for probe placement.
The probe should be snug but not too tight.
The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a well-child clinic is collecting data from four clients. Which of the following findings should the nurse report to the provider as a potential indication of child maltreatment?

Correct Answer is D

Explanation

A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Answer: B. Reposition the probe every 2 hours.

A nurse is planning to collect a stool specimen from an infant to check for the presence of ova and parasites. Which of the following actions should the nurse plan to take?

A nurse is reviewing the laboratory report of a newly admitted school-age child who has a fever. The nurse should identify which of the following laboratory results is an indication of an infection and should be reported to the charge nurse immediately.

A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

A nurse is reinforcing teaching with the parent of a 6-month-old infant about introducing solid foods into the infant's diet. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a preschooler who is in 90-90 traction. Which of the following is the nurse's priority action?

A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

A nurse is reinforcing teaching with the parents of a school-age child who has a new prescription for albuterol. The nurse should instruct the parents to report which of the following findings as an adverse effect of the medication.

A nurse is reinforcing teaching with a female adolescent who has dysmenorrhea. Which of the following instructions should the nurse include?