A nurse is caring for a 6-week-old infant in the pediatric unit.
Complete the diagram by dragging from the choices below to specify:
- What condition the client is most likely experiencing
- Two actions the nurse should take to address that condition
- Two parameters the nurse should monitor to assess the client’s progress
The Correct Answer is []
Actions to Take:
-
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.
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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:
-
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.
-
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
An increase in potassium levels is not an indicator of the effectiveness of furosemide, which is a diuretic used to reduce fluid overload.
Choice B rationale
A decrease in peripheral edema indicates that furosemide is effectively reducing fluid retention in the body.
Choice C rationale
A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart function.
Choice D rationale
An increase in venous pressure is not an indicator of the effectiveness of furosemide and may suggest fluid overload.
Correct Answer is D
Explanation
The correct answer is D. A school-age child who is in a spica cast.
Choice A rationale
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
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