The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure.

The infant’s vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute.

Which medication should the nurse hold and inform the health care provider?

Enalapril

Digoxin

Furosemide

Hydralazine

Answer and Explanation

The Correct Answer is B

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

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Correct Answer is C

Explanation

Choice A rationale
Recognizing most letters and numbers is a skill that typically develops later in childhood, not at 3 years old.
Choice B rationale
Using 1-word sentences is a skill that is typically mastered by 2 years old. A 3-year-old child is usually able to speak in longer sentences.
Choice C rationale
Speaking in simple sentences with four or more words is a normal developmental milestone for a 3-year-old child.
Choice D rationale
Using gestures with 1 to 2-word sentences is a skill that is typically mastered by 2 years old. A 3-year-old child is usually able to speak in longer sentences.

A. Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks. B. Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination. C. Take the child’s blood pressure three times during the visit and record the highest reading. D. Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Correct Answer is D

Explanation

The correct answer is choice d. Measure the blood pressure twice more during the visit and calculate the average of the three readings.

Choice A rationale:

Referring the child to the healthcare provider and scheduling a blood pressure evaluation in two weeks is not the immediate next step. It is important to confirm the elevated blood pressure reading during the same visit before making any referrals.

Choice B rationale:

Performing a comprehensive assessment and avoiding repeated blood pressure measurements is not appropriate. Repeated measurements are necessary to confirm the initial finding of elevated blood pressure.

Choice C rationale:

Taking the child’s blood pressure three times and recording the highest reading is not the best practice. The highest reading might not be representative of the child’s true blood pressure.

Choice D rationale:

Measuring the blood pressure twice more during the visit and calculating the average of the three readings is the correct approach. This method helps to ensure that the blood pressure reading is accurate and not influenced by temporary factors such as anxiety or movement.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

Correct Answer is C

Explanation

During a routine clinic visit, a nurse finds that a 5-year-old girl’s systolic blood pressure is above the 90th percentile. What should be the nurse’s subsequent action?

Correct Answer is D

Explanation

The parents of a newborn with hypospadias are anxious about the timing of the surgical correction. What information should the nurse share with them?

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The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

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