An 8-month-old infant is receiving Digoxin. The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which of the following?
90 bpm
60 bpm
120 bpm
100 bpm
The Correct Answer is D
A. 90 bpm is too low for an 8-month-old infant and not the standard threshold for withholding digoxin in this age group.
B. 60 bpm is the cutoff for adults, not infants.
C. 120 bpm is normal for an infant and does not warrant holding digoxin.
D. Correct. For infants, digoxin should be withheld and the provider notified if the apical heart rate is less than 100 beats per minute, due to the risk of bradycardia and digoxin toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The Oucher scale is a self-report pain scale appropriate for children 3 years and older who can point to a face that matches their pain intensity.
B. The FACES scale also relies on self-report and is best suited for children 3 years and older.
C. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is an observational pain assessment tool used for infants and young children who are unable to verbalize their pain, such as a 6-month-old.
D. The Visual Analog Scale requires the child to mark a point on a line to indicate pain intensity and is appropriate for older children and adults.
Correct Answer is A
Explanation
A. Frequent swallowing is a classic sign of post-tonsillectomy hemorrhage, as the child may be swallowing blood that is draining down the throat. This can be a subtle but early indicator of bleeding and requires immediate evaluation.
B. Increased pain is expected in the immediate postoperative period and not specific to hemorrhage.
C. Drooling may be due to throat pain or refusal to swallow but is not a key indicator of bleeding.
D. Poor fluid intake is common after tonsillectomy due to pain and discomfort, but not specific to hemorrhage.
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