A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?
Administer the next dose as prescribed
Mix the medication with 8 oz of formula
Give an antiemetic.
Increase fluid intake.
The Correct Answer is A
A. Vomiting after administering digoxin could be a sign of digoxin toxicity or intolerance. Before giving another dose, it is crucial to assess the infant’s condition, check for signs of digoxin toxicity, and consult with the healthcare provider. Administering the next dose without addressing the underlying issue could worsen the situation.
B. Mixing digoxin with a large volume of formula is not recommended. Digoxin should be administered in precise doses, and diluting it in such a large volume could lead to inaccuracies in dosing. Furthermore, mixing medication with formula does not address the issue of vomiting or potential toxicity.
C. While giving an antiemetic might seem like a solution to vomiting, it does not address the root cause of the vomiting, which could be related to digoxin toxicity or another issue. The first step should be to
assess the situation and determine if the vomiting is related to digoxin levels, and then consult with the healthcare provider. They may recommend appropriate interventions based on the infant’s condition.
D. Increasing fluid intake might be beneficial to prevent dehydration from vomiting, but it does not address the potential underlying cause of the vomiting, which could be related to digoxin toxicity. It is important to focus on the underlying cause and consult with the healthcare provider to determine the appropriate action. Managing fluid intake alone does not resolve the issue with digoxin or its side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex
typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.
Correct Answer is C
Explanation
A. This is typical behavior for an 18-month-old toddler. They often play alongside others without interacting directly.
B. This is a normal developmental milestone for an 18-month-old child.
C. An 18-month-old child should be able to walk independently. Difficulty walking with assistance could indicate a potential developmental delay.
D. While vocabulary varies, most 18-month-olds can say a few words. This is within the normal range.
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