The practical nurse (PN) administers digoxin to a 9-month-old infant with an apical heart rate of 160 beats/minute.
Which apical heart rate indicates that the therapeutic effect of the medication has been achieved?

Choice A rationale

Deep tendon reflexes are neurological assessments primarily used to evaluate neuromuscular excitability, particularly in conditions like preeclampsia where magnesium sulfate is administered. They are not indicated for managing fetal heart rate decelerations or chorioamnionitis, as these conditions do not directly impact spinal reflex arcs or necessitate this specific neurological monitoring. Normal reflexes range from 1+ to 2+.

Choice B rationale

Late decelerations, occurring after the peak of a contraction, indicate uteroplacental insufficiency, meaning reduced blood flow and oxygen to the fetus. A left side-lying position alleviates compression of the vena cava and aorta by the gravid uterus, thereby increasing venous return to the heart and improving uterine perfusion and oxygenation to the fetus, which is a crucial intervention.

Choice C rationale

Insertion of an indwelling urinary catheter to monitor hourly output is primarily indicated for assessing renal perfusion and fluid balance, particularly in critically ill clients or those at risk for fluid volume alterations, such as severe preeclampsia. It does not directly address or correct the underlying physiological cause of late fetal heart rate decelerations. Normal urine output is typically greater than 30 mL/hour.

Choice D rationale

Collecting a urine specimen for electrolytes and protein is a diagnostic measure for evaluating renal function, hydration status, and potential complications like preeclampsia, which presents with proteinuria. While important for overall assessment, it does not provide an immediate physiological intervention to improve uteroplacental perfusion and resolve acute fetal distress manifested by late decelerations.

Choice A rationale

Propping a bottle can lead to several adverse outcomes for an infant. It increases the risk of aspiration, as the infant may not be able to control the milk flow adequately. It can also contribute to otitis media due to milk pooling in the eustachian tubes and is associated with dental caries, particularly bottle mouth syndrome, and impaired bonding.

Choice B rationale

Sharing the observation with the charge nurse without first addressing the issue directly with the mother is not the most immediate or appropriate action. The PN should first attempt to educate and guide the mother, as this is within the scope of practice for direct client care and education.

Choice C rationale

Asking the mother if she is too tired is speculative and may be perceived as judgmental, potentially creating a barrier to effective communication and education. The PN's role is to provide health education and guidance regarding safe infant feeding practices, focusing on the behavior rather than the mother's perceived fatigue.

Choice D rationale

While observing the infant's behavior during feeding is important for a comprehensive assessment, the immediate and most critical action is to intervene with the unsafe practice of bottle propping. Observing further without addressing the identified risk delays necessary education and intervention to ensure infant safety.