A nurse is caring for a 6-week-old infant in the pediatric unit.

Exhibits

Complete the diagram by dragging from the choices below to specify:

1. What condition the client is most likely experiencing
2. Two actions the nurse should take to address that condition
3. Two parameters the nurse should monitor to assess the client’s progress

Actions to Take:

1. Anticipate a prescription for digoxin:

   • Digoxin is commonly used in pediatric heart failure cases to improve the strength of the heart’s contractions, helping to increase cardiac output and reduce symptoms of CHF. The nurse should anticipate its use to help manage the infant’s heart function.

2. Elevate the head of the bed to a 45° angle:

   • This action helps reduce the work of breathing and decreases venous return to the heart, which can alleviate pulmonary congestion and improve respiratory function. Positioning the infant in a semi-upright position is crucial to relieve symptoms of CHF, especially when there’s evidence of respiratory distress.

Parameters to Monitor:

1. Peripheral pulses:

   • Monitoring peripheral pulses is essential in assessing the effectiveness of the heart’s ability to pump blood. The weak pedal pulses and bounding upper extremity pulses noted earlier are significant findings that need to be monitored to gauge improvement in circulation as the infant’s condition is managed.

2. Respiratory status:

   • Respiratory rate, effort (including retractions and nasal flaring), and oxygen saturation levels must be closely monitored to track the infant's progress. Improvement in respiratory status, along with reduced crackles, would indicate a reduction in pulmonary congestion.