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.

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.