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?

Choice A Reason:

"Encourage your partner to eat three large meals each day." In end-of-life care, the focus shifts from large meals to providing comfort and meeting the patient's nutritional needs, which might not involve large meals due to potential decreased appetite or difficulty swallowing.

Choice B Reason:

"We will use an electric blanket to keep your partner warm. “While keeping the patient warm is essential, the use of an electric blanket might not always be appropriate due to the risk of burns or changes in sensation that can occur in some conditions.

Choice C Reason:

"Opioids will be restricted if your partner develops respiratory distress. “This statement might not convey the full context of pain and symptom management in end-of-life care. Opioids are often used judiciously to manage distressing symptoms, including pain and respiratory distress, under careful monitoring rather than being strictly restricted.

Choice D Reason:

"Assume your partner can hear you, even if they do not respond." This statement emphasizes the importance of communication and connection with the partner who may be unresponsive. Research suggests that hearing may persist even when a person is unable to respond, so speaking to the person respectfully and with care can provide comfort and support during this time.

Choice A Reason:

Exhibits head lag when pulled to a sitting position is correct. At 5 months old, infants typically show improvement in head control, and head lag (where the infant's head falls back when pulled to a sitting position) should be diminishing. Persistent head lag might indicate potential developmental concerns or issues with muscle tone that warrant further evaluation by the healthcare provider.

Choice B Reason:

Unable to hold a bottle is incorrect. At 5 months old, some infants might not have developed the ability to hold a bottle independently yet. This skill can vary among infants and might not be a significant concern at this stage.

Choice C Reason:

Unable to roll from back to abdomen is incorrect. Rolling from back to abdomen might not be fully developed in all infants at 5 months old. It's a milestone that some infants achieve later within the 5 to 6-month range, so it might not be an immediate concern unless it persists significantly beyond that range.

Choice D Reason:

Absent grasp reflex is incorrect. By 5 months old, the typical infant's grasp reflex usually starts to diminish as voluntary grasping begins to develop. However, the absence of the grasp reflex might not be an immediate concern unless it's accompanied by other signs of developmental delay or regression.