Before giving a dose of digoxin (Lanoxin), the nurse checked an infant's apical heart rate and it was 114 bpm. What should the nurse do next?
Administer the dose as ordered.
Hold the medication until the next dose.
Wait and recheck the apical heart rate in 30 minutes.
Notify the physician about the Infant's heart rate.
The Correct Answer is A
A. Administer the dose as ordered: In infants, digoxin is typically held if the apical heart rate is below 90–110 bpm. An apical rate of 114 bpm is above the threshold, so it is safe to administer the medication while continuing to monitor for signs of toxicity.
B. Hold the medication until the next dose: Holding digoxin unnecessarily can compromise therapeutic effectiveness and cardiac output, especially in infants with heart failure. Medication should only be held if the heart rate is below the established threshold.
C. Wait and recheck the apical heart rate in 30 minutes: Rechecking is unnecessary if the initial assessment shows a heart rate within safe limits. Delaying administration without cause may disrupt the medication schedule and its efficacy.
D. Notify the physician about the infant's heart rate: The heart rate is within an acceptable range for digoxin administration, so notifying the physician is not required in this instance. Routine monitoring and documentation are sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pulmonary stenosis: Pulmonary stenosis typically produces a systolic ejection murmur heard best at the upper left sternal border. The murmur is not continuous and does not have the classic machinery-like quality associated with PDA.
B. Patent ductus arteriosus: Patent ductus arteriosus (PDA) allows blood to flow from the aorta to the pulmonary artery, creating a continuous “machinery-like” murmur that is heard throughout systole and diastole. This distinctive murmur is most prominent at the left upper sternal border and is characteristic of PDA, particularly in premature infants.
C. Ventricular septal defect: A ventricular septal defect usually produces a harsh, holosystolic murmur at the lower left sternal border. The murmur is confined to systole and lacks the continuous, machinery-like quality of PDA.
D. Coarctation of the aorta: Coarctation of the aorta often presents with systolic murmurs, diminished femoral pulses, and differential blood pressures between upper and lower extremities. The murmur is not continuous and does not produce the machinery-like sound seen in PDA.
Correct Answer is D
Explanation
A. Postpartum infection: While all postpartum clients are at some risk for infection, this typically develops later and is not immediately associated with a large infant or the first few hours after birth.
B. Retained placental fragments: Retained placental tissue can cause bleeding and infection, but careful inspection of the placenta after delivery usually rules this out. There is no indication in the scenario that fragments remain.
C. Thrombophlebitis: Thromboembolic risk increases postpartum, especially with immobility, obesity, or a history of thrombosis. Although this client may have some risk factors, immediate concern in the first hours postpartum is more directly related to uterine tone.
D. Uterine atony: Delivery of a macrosomic infant (9 lb 6 oz) increases the risk of uterine overdistention, which can lead to poor uterine contraction and uterine atony. Uterine atony is the most common cause of early postpartum hemorrhage and requires close monitoring and intervention.
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