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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Factor VIII concentrate is used to treat hemophilia, not iron deficiency anemia.
B. Ferrous sulfate is an iron supplement commonly used to treat iron deficiency anemia.
C. Good oral hygiene is important but it does not directly address the underlying issue of iron deficiency anemia.
D. There is no need for protective precautions in iron deficiency anemia.

A. "Use a soft-bristled toothbrush when platelet levels are low." B. "Encourage eating by providing your child with their favorite foods." C. "Rinse your child's mouth with chlorhexidine mouthwash if they develop stomatitis." D. "Ensure you administer an antiemetic for 12 hr after chemotherapy."

Correct Answer is A

Explanation

A. Chemotherapy can decrease platelet count, increasing the risk of bleeding. A soft-bristled toothbrush helps prevent gum bleeding.
B. This might help stimulate appetite but it doesn't address the specific concerns related to chemotherapy side effects.
C. If stomatitis develops, which is a painful inflammation and ulceration of the mouth, rinsing with a mild saline solution is generally recommended rather than chlorhexidine mouthwash, which can sometimes cause irritation.
D. Antiemetics should be administered as needed based on the child's symptoms, not on a fixed schedule.

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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?

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