The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin.

The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was:

Choice A rationale

Providing false reassurance, such as stating "he will be okay," is not therapeutic because the outcome is uncertain, especially during active resuscitation efforts. The nurse must maintain honesty and support while acknowledging the gravity of the situation. Offering simple presence and resource information is much more supportive and appropriate for the family.

Choice B rationale

This response inappropriately questions the parents' actions and implies blame or judgment during an emotionally devastating crisis. Such a statement is highly unsupportive, unprofessional, and potentially damaging to the therapeutic relationship. The focus must remain on providing comfort, support, and necessary information to the grieving family.

Choice C rationale

Although it attempts to validate their feelings of fear, this response focuses on a specific, potentially guilt-inducing detail (the driving) which is likely irrelevant to the immediate need for support. It may exacerbate parental guilt during a critical time. A supportive response should be broad and non-judgmental, addressing their general distress and needs.

Choice D rationale

This statement is the most appropriate and therapeutic response, as it conveys non-judgmental presence, validation of the family's difficult emotional state, and an offer to provide information and answer questions. It establishes the nurse as a supportive resource for the family during a time of extreme crisis and uncertainty, which is the primary nursing role.

Choice A rationale

This statement reflects correct knowledge because head lice infestations, or pediculosis capitis, are highly contagious and spread through close contact or shared items, making it essential to check all household members to prevent reinfestation and ensure effective eradication of the parasites.

Choice B rationale

This statement supports a nursing diagnosis of knowledge deficit because it indicates a misconception that head lice are associated only with poor hygiene or low socioeconomic status, when in fact, lice infestation is unrelated to cleanliness and can occur in any population group through head-to-head contact.

Choice C rationale

This statement demonstrates correct knowledge because itching, particularly around the ears, neck, and scalp, is a common clinical manifestation of pediculosis capitis, caused by the louse saliva irritating the scalp, thus the parent correctly links the symptom to the new diagnosis.

Choice D rationale

This statement shows correct understanding of treatment because the nit comb is crucial for manually removing nits (lice eggs) that may remain attached to the hair shaft even after chemical pediculicide treatment, which often only kills live lice but not all the eggs.