A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr. of administration.
Administer cool, humidified oxygen via nasal cannula
Provide less frequent, higher volume feedings
The Correct Answer is C
Choice A Reason:
Placing the infant in a prone position might not be suitable for an infant with heart failure. Typically, an upright or semi-upright position can help reduce the workload on the heart by improving respiratory function and aiding in cardiac output.
Choice B Reason:
Repeating a digoxin dosage if the infant vomits within 1 hour of administration isn't recommended without consulting a healthcare provider. If vomiting occurs within this time frame, giving another dose might result in overdosing.
Choice C Reason:
Administering cool, humidified oxygen via nasal cannula can be beneficial for an infant with heart failure, as it helps in providing supplemental oxygen and maintaining adequate oxygenation levels.
Choice D Reason:
Providing less frequent, higher volume feedings might not be appropriate for an infant with heart failure. These infants often require smaller, more frequent feedings to prevent overloading the digestive system and to manage fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"We will apply lotion to the skin under the straps." Applying lotion under the straps might create moisture, interfere with the harness's function, or cause skin irritation. It's generally recommended to avoid lotions or creams under the straps.
Choice B Reason:
"We should expect our baby to wear this harness for 2 weeks." The duration for wearing a Pavlik harness can vary significantly depending on the severity of the hip dysplasia and the infant's response to treatment. The duration is determined by the healthcare provider's assessment and may extend beyond 2 weeks.
Choice C Reason:
"We will place the diaper under the straps." Placing the diaper under the straps helps prevent skin irritation and chafing caused by the straps rubbing against the skin. It ensures that the skin remains protected and reduces the risk of skin breakdown or discomfort for the infant.Pavlik harnesses are typically designed to keep the hips in a specific position, and diapers should be placed underneath to avoid leaks soiling the harness
Choice D Reason:
"We should adjust the straps daily." Adjusting the straps of a Pavlik harness should only be done by a healthcare professional to ensure proper positioning and safety.
Correct Answer is C
Explanation
Choice A Reason
Pulse rate 98/min: A pulse rate of 98 beats per minute is within the expected range for a 2-year-old child (normal range: 70-110 bpm). This finding is generally considered normal for this age and may not require immediate reporting.
Choice B Reason:
Temperature 37.2° C (99° F): A temperature of 37.2°C (99°F) is slightly elevated but is within the range of low-grade fever in children. However, at a well-child visit, this temperature might not be immediately alarming, especially if the child doesn't exhibit other signs of illness.
Choice C Reason:
Blood pressure 118/74 mm Hg:This reading is higher than the normal range for a 2-year-old child. High blood pressure in a young child should be evaluated further to determine the cause and need for intervention.
Choice D Reason:
Respiratory rate 26/min: The normal respiratory rate for a 2-year-old child typically ranges from 20 to 30 breaths per minute. A respiratory rate of 26 breaths per minute is within this range and may not warrant immediate concern.
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