The nurse should teach a pregnant woman that which substances are teratogens? (Select all that apply.).

Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.

E.

Choice A rationale:

Administer antibiotics. Rationale: Antibiotics are not indicated for respiratory syncytial virus (RSV) bronchiolitis, which is caused by a viral infection. RSV is a common cause of bronchiolitis in infants, and antibiotics do not treat viral infections. Using antibiotics in this situation would not be appropriate and can contribute to antibiotic resistance.

Choice B rationale:

Administer cough syrup. Rationale: Cough syrups are generally not recommended for infants and young children due to the risk of overdosing and potential adverse effects. Additionally, RSV bronchiolitis primarily requires supportive care and management of respiratory symptoms, which may include oxygen therapy in severe cases.

Choice C rationale:

Encourage infant to drink 8 ounces of formula every 4 hours. Rationale: Maintaining hydration is essential in the management of RSV bronchiolitis. However, the specific volume and frequency of formula intake may vary based on the infant's age, weight, and overall condition. It is important to assess the infant's tolerance and adjust the feeding schedule accordingly. Encouraging frequent, smaller feeds might be more appropriate for some infants to prevent overfeeding and vomiting.

Choice D rationale:

Institute cluster care to encourage adequate rest. Rationale: Cluster care, a nursing intervention involving grouping activities to minimize disturbances and promote longer periods of rest, is beneficial for infants with RSV bronchiolitis. Adequate rest helps conserve the infant's energy, facilitating the recovery process. This intervention supports the infant's overall well-being and aids in coping with respiratory distress.

Choice E rationale:

Place on noninvasive oxygen monitoring. Rationale: Infants with severe RSV bronchiolitis may experience respiratory distress and hypoxia, necessitating oxygen therapy. Noninvasive oxygen monitoring methods, such as pulse oximetry, allow healthcare providers to assess oxygen saturation levels without invasive procedures. Oxygen therapy can improve oxygenation and alleviate respiratory distress, supporting the infant's respiratory function and overall recovery.