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 C
Explanation
A. The right arm: Measuring blood pressure in only one arm can miss important pressure discrepancies that occur with certain congenital heart defects, particularly those involving obstruction of systemic blood flow. Upper-extremity readings alone do not provide a complete hemodynamic picture.
B. The left arm: While the left arm may reflect systemic circulation, isolated measurement does not allow comparison between upper and lower extremities, which is essential for detecting defects such as coarctation of the aorta. A single-site reading limits diagnostic value.
C. All four extremities: Congenital heart defects, especially coarctation of the aorta, often cause higher blood pressure in the arms and lower pressure in the legs due to narrowing of the aorta distal to the subclavian arteries. Measuring all four extremities allows detection of pressure gradients that strongly suggest CHDs.
D. Both arms while the child is crying: Crying can falsely elevate blood pressure due to sympathetic stimulation and does not provide reliable or comparative data. Additionally, measuring only the arms fails to assess lower-extremity perfusion differences critical in CHD evaluation.
Correct Answer is B
Explanation
A. It is a type IV hypersensitivity reaction: Urticaria is typically a type I hypersensitivity reaction mediated by IgE, not a delayed type IV reaction. Type IV reactions involve T-cell–mediated responses, such as contact dermatitis, rather than immediate histamine-mediated reactions.
B. Histamine release leads to vasodilation: Urticaria results from mast cell degranulation and histamine release, which increase vascular permeability and cause local vasodilation. This leads to the characteristic erythema, swelling, and itching associated with hives.
C. Wheals appear first followed by erythema: In urticaria, erythema and wheals usually appear simultaneously as a result of histamine-induced vasodilation and plasma leakage into the dermis. There is no distinct sequence of wheals followed by erythema.
D. The nonpruritic rash blanches with pressure: Urticarial lesions are typically pruritic (itchy), not nonpruritic, and may blanch under pressure due to transient vasodilation. Pruritus is a hallmark symptom distinguishing urticaria from other rashes.
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