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 B
Explanation
Choice A rationale:
Soaking combs and brushes in boiling water for 10 minutes is a good practice to kill scabies mites that might be present on these items. However, it's not the primary mode of transmission for scabies. Scabies spreads through direct, prolonged, skin-to-skin contact with a person who has scabies. While cleaning items like combs and brushes is essential, treating close contacts is more critical to prevent reinfestation.
Choice B rationale:
Treating everyone who came into close contact with the child is the correct approach. Scabies is highly contagious and can easily spread to family members and close contacts. To effectively control the spread of the infestation, everyone who has been in close contact with the infested person should be treated simultaneously, even if they do not show symptoms.
Choice C rationale:
Applying petroleum jelly to the affected areas is not a recommended treatment for scabies. Scabies is caused by the Sarcoptes scabiei mite burrowing into the skin, and petroleum jelly does not effectively kill the mites. Medicated creams or lotions prescribed by a healthcare provider are the standard treatment for scabies.
Choice D rationale:
Washing the child's hair with shampoo containing ketoconazole is not a recommended treatment for scabies. Ketoconazole is an antifungal medication and is not effective against scabies mites. The primary treatment for scabies involves topical medications, such as permethrin cream or oral medications in severe cases.
Correct Answer is B
Explanation
Choice A rationale:
Limb withdrawal is a pain response and indicates that the infant is experiencing pain. The goal of opioid pain medication is to alleviate pain, so limb withdrawal suggests inadequate pain control.
Choice B rationale:
A relaxed facial expression indicates that the infant is comfortable and not experiencing pain. It is a positive sign that the medication is having a therapeutic effect by providing pain relief.
Choice C rationale:
Increased blood pressure is not a typical response to opioid pain medication. Opioids often cause a decrease in blood pressure and can lead to hypotension.
Choice D rationale:
Bradycardia (slow heart rate) is not a common response to opioid pain medication. Opioids can cause respiratory depression and bradypnea (slow breathing), but they do not typically cause bradycardia.
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