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:
A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.
Choice B reason:
A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.
Choice C reason:
Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.
Choice D reason:
While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Obtaining the infant's weight with their diaper on should be avoided as this can alter the result.
Choice B reason:
Placing a stadiometer on the top of the infant's head to measure their length can harm or distress the infant.
Choice C reason:
Ensuring the scale is at 0 is important in obtaining an accurate weight Choice D reason:
Covering the scale with paper is recommended for hygiene purposes
Choice E reason:
This method provides an accurate measurement of the infant's length.
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