A nurse is providing care to an infant who has tetralogy of Fallot. The infant's caregiver reports increased irritability and a bluish discoloration of the infant's oral mucous membranes. Which of the following interventions is the nurse's priority?

Rationale:

A. Laxatives are contraindicated for postpartum clients is incorrect because laxatives are not universally contraindicated in the postpartum period. While strong stimulant laxatives may be used cautiously, many postpartum clients, especially those recovering from vaginal tears, episiotomies, or cesarean births, are safely prescribed stool softeners such as docusate sodium. These help prevent straining, which could increase pain or disrupt healing. Therefore, stating that all laxatives are contraindicated is inaccurate.

B. Stay hydrated throughout the day is correct because adequate hydration is one of the most effective and essential interventions for relieving constipation, especially in the postpartum period. Increased fluid intake softens stool, promotes bowel motility, and counteracts the dehydrating effects of labor, blood loss, and breastfeeding. Many postpartum clients experience slowed bowel function due to decreased abdominal muscle tone, analgesic use, fear of pain, and hormonal changes; hydration directly helps restore normal bowel movements.

C. Daily enemas are needed to relieve constipation is incorrect because enemas are not recommended as a routine measure postpartum. Frequent enemas can irritate the rectal mucosa, cause electrolyte imbalance, and create dependency. They are reserved only for severe constipation and used only under provider supervision. Teaching a client to rely on daily enemas is inappropriate and potentially harmful.

D. Avoid fiber-rich foods, as they can worsen constipation is incorrect because fiber plays a key role in promoting regular bowel movements. Fiber adds bulk to stool, stimulates peristalsis, and improves stool consistency. Postpartum clients are encouraged to consume whole grains, fruits, vegetables, and legumes to help restore normal bowel habits. Avoiding fiber would likely worsen constipation rather than alleviate it.

Rationale:

A. Request a dietitian consult is incorrect because dietary modifications may be important for a child with congestive heart failure, but this is not the immediate priority when the client is showing potential signs of digoxin toxicity.

B. Check the client's vital signs is correct because nausea, vomiting, and weakness in a child taking digoxin can indicate digoxin toxicity, which can affect heart rate and rhythm. The nurse should first assess vital signs, particularly the heart rate, as digoxin toxicity can cause bradycardia or other dysrhythmias, which may be life-threatening. Assessment is always the first step according to the nursing process and the principle of safety first.

C. Request an order for an antiemetic is incorrect because treating symptoms without assessing the client could mask a potentially serious medication-related complication. Administering an antiemetic would not address the underlying risk of toxicity.

D. Suggest that the client rests before eating the meal is incorrect because resting does not address the potential danger of digoxin toxicity. Weakness and nausea may indicate cardiac compromise, so immediate assessment is necessary before implementing comfort measures.