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.
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
Provide less frequent, higher volume feedings.
The Correct Answer is A
Infants with heart failure often present with breathing trouble1, and administering oxygen can help improve oxygen delivery.
Choice B is wrong because placing an infant in a prone position does not help with heart failure.
Choice C is wrong because if an infant vomits within 1 hour of administration of digoxin, the dosage should not be repeated without consulting a healthcare provider.
Choice D is wrong because infants with heart failure may have feeding issues and providing less frequent, higher volume feedings may not be helpful34.
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Related Questions
Correct Answer is B
Explanation
This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Correct Answer is B
Explanation
The nurse should initiate droplet isolation precautions when admitting a child who has acute epiglottitis.
Epiglottitis is commonly caused by Haemophilus influenzae type B and can be transmitted through respiratory droplets.
Choice A is wrong because obtaining a throat culture is not recommended when epiglottitis is suspected, as it can cause further obstruction of the airway.
Choice C is wrong because assisting the child into a supine position can worsen the airway obstruction.
Children with epiglottitis prefer to sit upright with the chin extended and mouth open.
Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child with acute epiglottitis who may require continuous monitoring of oxygen saturation.
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