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A nurse is caring for a 6-week-old infant.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing

Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.

Actions to Take

Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.

Parameters to Monitor

Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.

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Correct Answer is A

Explanation

Vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels and inadequate therapeutic effect. The plan of care should be revised to address the vomiting and consider alternative routes of administration or doses.

A digoxin level within the therapeutic range indicates adequate drug absorption and effectiveness.

An apical pulse of 100/min is within the expected range for toddlers and does not necessarily require a revision of the plan of care related to digoxin therapy.

A potassium level within the normal range is desirable and does not necessarily require a revision of the plan of care related to digoxin therapy.

A. Vomiting B. Hypertension C. Rounded abdomen D. Tachypnea

Correct Answer is C

Explanation

A. While vomiting can be a symptom in some gastrointestinal disorders, it is not specific to necrotizing enterocolitis.
B. Hypertension is not typically associated with necrotizing enterocolitis. Instead, infants may present with hypotension due to septic shock or poor perfusion.
C. A rounded abdomen is a common finding in infants with necrotizing enterocolitis due to abdominal distension from gas and fluid accumulation.
D. Tachypnea may occur in response to systemic infection or respiratory distress but is not a defining characteristic of necrotizing enterocolitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following toddlers should the nurse revise the plan of care?

Correct Answer is A

Explanation

A nurse is caring for an infant who has necrotizing enterocolitis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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