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?
Administer cool, humidified oxygen via nasal cannula.
Provide less frequent, higher volume feedings.
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
The Correct Answer is A
Choice A rationale:
Administer cool, humidified oxygen via nasal cannula. Infants with heart failure often experience respiratory distress due to inadequate oxygenation. Administering cool, humidified oxygen via nasal cannula helps improve oxygen saturation and alleviate respiratory distress. Humidified oxygen prevents the mucous membranes from drying out, making breathing easier for the infant. Cool oxygen is preferred to reduce the work of breathing and to soothe irritated airways, improving the overall comfort of the infant.
Choice B rationale:
Provide less frequent, higher volume feedings. Infants with heart failure may have difficulty feeding due to fatigue and increased respiratory effort. Providing less frequent, higher volume feedings ensures that the infant receives adequate nutrition without becoming overly fatigued during feeding sessions. It allows the infant to obtain the necessary nutrients without putting excessive stress on their weakened cardiovascular system.
Choice C rationale:
Place the infant in a prone position. Placing the infant in a prone position is not recommended in the care of a child with heart failure. Placing the infant in an upright or semi-upright position is more appropriate as it reduces the workload on the heart and improves respiratory function. Placing the infant flat on their back may cause increased pressure on the diaphragm and worsen respiratory distress.
Choice D rationale:
Repeat a digoxin dosage if the infant vomits within 1 hr of administration. Digoxin is a medication commonly prescribed for heart failure. However, if the infant vomits shortly after receiving a dose, repeating the dose is not advisable. Vomiting may indicate that the medication was not properly absorbed, and administering an additional dose could lead to an overdose. Instead, the nurse should consult the healthcare provider for further instructions and closely monitor the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The preschool-age child with muffled voice and no spontaneous cough might be experiencing a medical emergency, possibly epiglottitis. This condition can rapidly progress and compromise the airway, necessitating immediate assessment and intervention.
Choice B rationale:
The school-age child with diabetes and a blood glucose of 200 mg/dL requires attention, but it is not an immediate concern unless the child is showing signs of diabetic ketoacidosis (DKA), such as altered mental status or deep, labored breathing, which are not mentioned in the question.
Choice C rationale:
The toddler with nephrotic syndrome and facial edema needs monitoring and intervention, but it doesn't indicate an immediate life-threatening condition compared to the child with potential airway compromise (muffled voice and no spontaneous cough)
Choice D rationale:
The adolescent with Crohn's disease and recent weight loss also needs attention, but it's not as urgent as the child with potential airway obstruction. Weight loss alone, while concerning, doesn't necessitate immediate assessment in this context.
Correct Answer is D
Explanation
Choice A rationale:
Staying under a beach umbrella during morning hours provides some protection from direct sunlight but does not offer comprehensive coverage, especially when the sun's rays are strong. It is not the best option for protecting a toddler from sun exposure.
Choice B rationale:
SPF (Sun Protection Factor) 10 sunscreen is relatively low and may not provide adequate protection, especially for a toddler. Higher SPF sunscreens are recommended, typically SPF 30 or higher, to effectively block harmful UV rays.
Choice C rationale:
Loose-weave clothing may allow sunlight to penetrate, leading to sunburn. Tight-knit, dark-colored clothing offers better protection. Loose-weave clothing is not the most effective choice for sun protection.
Choice D rationale:
Wearing a wide-brimmed hat provides shade to the face, neck, and ears, offering additional protection from direct sunlight. This choice indicates a good understanding of the need for comprehensive sun protection for the toddler.
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