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 test will measure the amount of chloride in your baby's sweat." Pilocarpine iontophoresis testing is used to diagnose cystic fibrosis by measuring the chloride content in the patient's sweat. Cystic fibrosis patients have elevated chloride levels in their sweat, which is a characteristic feature of the disease. Educating the parents about the purpose of the test helps them understand its significance in diagnosing their baby's condition.
Choice B rationale:
"We will measure the amount of protein in your baby's urine over a 24-hour period." Measuring protein in urine over a 24-hour period is a test for kidney function, not for cystic fibrosis. This statement is unrelated to the pilocarpine iontophoresis testing and may confuse the parents about the purpose of the procedure.
Choice C rationale:
"Your baby will need to fast for 8 hours prior to the test." Fasting is not a requirement for pilocarpine iontophoresis testing. This statement is incorrect and could cause unnecessary stress for the parents and the infant. It is essential to provide accurate information to ensure that the parents are well-prepared for the procedure.
Choice D rationale:
"A nurse will insert an IV prior to the test." Inserting an IV is not a part of the pilocarpine iontophoresis testing procedure. This statement is inaccurate and does not contribute to the parents' understanding of the test. Providing irrelevant information can create confusion and anxiety, which should be avoided during patient education.
Correct Answer is ["A","B","D"]
Explanation
D.
Choice A rationale:
Fever is a common sign of acute otitis media, indicating an infection. Elevated body temperature is a natural response to infection as the body tries to fight off the invading pathogens.
Choice B rationale:
Crying is a common symptom in infants with acute otitis media due to ear pain and discomfort caused by the infection. It is a way for the infant to express distress.
Choice C rationale:
Enlarged subclavicular lymph node is not a typical finding in acute otitis media. Enlarged lymph nodes can indicate an immune response but are not specific to this condition.
Choice D rationale:
Restlessness can be a symptom of acute otitis media. Infants may become irritable and have difficulty sleeping due to ear pain and discomfort.
Choice E rationale:
Increased appetite is not a typical finding in acute otitis media. Illnesses often cause a decreased appetite rather than an increased one.
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