A nurse is caring for an 8-year-old child who has a new onset of generalized seizures. Which of the following interventions should the nurse include in the plan of care?

Rationale for correct choices

• Congestive heart failure: The infant exhibits signs of fluid overload and decreased cardiac output, including tachypnea, retractions, nasal flaring, crackles in all lung fields, tachycardia, bounding upper extremity pulses, weak pedal pulses, periorbital edema, dry mucous membranes, and poor weight gain. Chest x-ray shows mild left ventricular hypertrophy and increased pulmonary vascular markings, consistent with congestive heart failure.

• Anticipate a prescription for digoxin: Digoxin is used to improve cardiac contractility and decrease heart rate, thereby enhancing cardiac output in infants with heart failure. Preparing for administration allows the nurse to ensure appropriate dosing, monitor for toxicity, and educate caregivers regarding signs of overdose. Close monitoring of heart rate and rhythm is essential before each dose.

• Oxygen supplementation: The infant’s oxygen saturation is 90% on room air, indicating hypoxemia. Supplemental oxygen improves oxygen delivery to tissues, reduces work of breathing, and prevents further cardiac stress. Continuous monitoring ensures safe oxygenation and guides titration based on respiratory status.

• Intake and output: The infant shows signs of dehydration (dry diaper for 10 hours, decreased skin turgor) and fluid overload (edema). Monitoring intake and output assesses fluid balance, guides fluid replacement or restriction, and evaluates the effectiveness of diuretics or other interventions.

• Respiratory status: Tachypnea, retractions, nasal flaring, and crackles indicate respiratory compromise secondary to pulmonary congestion. Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of deterioration and informs adjustments in oxygen therapy or pharmacologic management.

Rationale for incorrect choices

• Pyloric stenosis: Pyloric stenosis presents with projectile, non-bilious vomiting, a palpable “olive” mass in the abdomen, and signs of dehydration. The infant’s presentation with pulmonary congestion, edema, and tachypnea does not align with pyloric stenosis.

• Respiratory syncytial virus (RSV) bronchiolitis: RSV causes respiratory distress, wheezing, and hypoxia, but it does not explain poor weight gain, periorbital edema, bounding pulses, or left ventricular hypertrophy seen on chest x-ray. The systemic signs point to cardiac etiology rather than viral infection.

• Cystic fibrosis: Cystic fibrosis typically presents with failure to thrive, steatorrhea, recurrent respiratory infections, and salty skin. There is no evidence of digestive malabsorption or recurrent pulmonary infections, making CF less likely.

• Implement contact precautions: No infectious etiology is suggested; contact precautions are unnecessary. The priority is addressing heart failure and associated respiratory compromise.

• Place nasogastric tube for gastric decompression: There is no evidence of gastrointestinal obstruction or distension requiring decompression. Nutrition and fluid management are the focus rather than decompression.

• Provide chest physiotherapy and postural drainage: Chest physiotherapy is indicated for conditions with thick pulmonary secretions (e.g., cystic fibrosis) but is not indicated for pulmonary congestion secondary to heart failure, where fluid overload rather than mucus accumulation is the issue.

• Number of steatorrhea stools: Steatorrhea monitoring is relevant for malabsorption or cystic fibrosis but not for congestive heart failure. The infant’s issue is primarily cardiovascular.

• Blood glucose: Blood glucose is not immediately relevant to assessing the infant’s heart failure or fluid balance and is not needed for monitoring progress in this scenario.

• Irritability: The child is restless and agitated, which is common in both upper and lower respiratory infections. Irritability reflects systemic response to infection, fever, and airway discomfort. It is an important indicator for monitoring respiratory status and overall well-being.

• Stridor: Inspiratory stridor is a hallmark of croup (acute laryngotracheobronchitis) due to airway inflammation and narrowing in the larynx and trachea. Stridor is typically absent in pneumonia, which primarily affects the lower airways.

• Temperature: The child has a low-grade fever (38.1–38.2° C), which is common in both croup and pneumonia. Fever indicates an inflammatory response to infection, and monitoring trends is important for evaluating disease progression or complications.

• Cough findings at 0800: The barking, non-productive cough is characteristic of croup, caused by inflammation of the upper airway. Pneumonia usually produces a productive cough with sputum and may involve lower respiratory symptoms like wheezing, crackles, or decreased breath sounds.