A nurse is caring for an infant who has heart failure and a new prescription for digoxin.Which of the following findings should the nurse report to the provider?
Weight loss 0.25 kg (0.55 lb)
Vomiting twice in 4 hr
Respiratory rate 30/min
Heart rate 130/min
The Correct Answer is B
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Collecting a stool specimen for occult blood is not the most relevant test for suspected
Clostridium difficile infection. Stool culture or testing for C. difficile toxins is more appropriate.
Choice B reason:
Conducting a tape test is used to diagnose pinworms, not Clostridium difficile infection.
Choice C reason:
This statement is correct. Obtaining a stool specimen for culture, specifically for C. difficile, is the appropriate action for suspected infection.
Choice D reason:
Drawing a blood culture is not the primary diagnostic test for Clostridium difficile. Stool culture or testing for C. difficile toxins is more appropriate.
Correct Answer is B
Explanation
Choice A reason:
Using a bulb syringe for suctioning is not the appropriate intervention for a choking infant. This may not effectively clear the airway obstruction.
Choice B reason:
Delivering back blows with the infant face down over the rescuer's arm is the recommended action for relieving a choking episode in an infant. This helps to dislodge the obstruction from the airway.
Choice C reason:
Placing the infant in a side-lying position and performing abdominal thrusts is the intervention for a conscious infant who is choking. This is not the appropriate action for an infant showing circumoral cyanosis.
Choice D reason:
Performing a head tilt and chin lift followed by giving rescue breaths is the procedure for providing rescue breaths in infant CPR. It is not the initial intervention for a choking infant.
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