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?
60 beats/minute.
120 beats/minute.
80 beats/minute.
180 beats/minute.
The Correct Answer is B
Choice A rationale
A heart rate of 60 beats/minute for a 9-month-old infant is significantly below the normal physiological range (90-140 beats/minute). Digoxin primarily acts to slow the heart rate and increase contractility, but such a low rate indicates severe bradycardia, a potentially dangerous adverse effect of digoxin toxicity due to excessive parasympathetic stimulation and impaired atrioventricular conduction.
Choice B rationale
A heart rate of 120 beats/minute is within the normal resting range for a 9-month-old infant, which typically falls between 90-140 beats/minute. Digoxin’s therapeutic effect in infants with cardiac conditions often aims to bring the heart rate to a more efficient and less tachycardic rate, thereby improving cardiac output without causing bradycardia.
Choice C rationale
A heart rate of 80 beats/minute is below the typical normal range for a 9-month-old infant (90-140 beats/minute). While digoxin can decrease heart rate, 80 beats/minute suggests an excessive therapeutic effect, potentially indicating mild bradycardia which could compromise cardiac output and tissue perfusion.
Choice D rationale
A heart rate of 180 beats/minute is significantly above the normal physiological range for a 9-month-old infant (90-140 beats/minute). This elevated rate indicates persistent tachycardia, suggesting that the digoxin has not achieved its therapeutic effect of slowing the heart rate, or that the underlying cardiac issue is not adequately controlled.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
An acceleration is a visually apparent abrupt increase in the fetal heart rate above the baseline. For a 38-week fetus, an acceleration is defined as an increase of 15 beats per minute or more above the baseline, lasting 15 seconds or more but less than 2 minutes. The given finding of 10 seconds does not meet this criterion.
Choice B rationale
While fetal movement often accompanies accelerations, documenting "fetal movement" alone is insufficient. The nonstress test specifically assesses the fetal heart rate response to movement, and the critical finding to document relates to the FHR pattern itself, not just the presence of movement.
Choice C rationale
A positive tracing in obstetrics typically refers to a positive contraction stress test, which indicates late decelerations and is an abnormal finding. This terminology is not applicable to a nonstress test, where the terms "reactive" or "nonreactive" are used to describe the findings.
Choice D rationale
A nonreactive pattern on a nonstress test for a 38-week fetus is defined by the absence of two or more accelerations (15 bpm above baseline for at least 15 seconds) within a 20-minute period. The observed FHR increases lasting only 10 seconds do not meet the duration criteria for reactivity.
Correct Answer is B
Explanation
Choice A rationale
A visit summary documenting the report of abuse may be legally required for documentation but does not directly provide the client with immediate safety resources. The priority is to empower the client with actionable steps to ensure her safety and well-being in an abusive situation.
Choice B rationale
Contact information for a women's shelter provides a crucial immediate resource for safety and support. These shelters offer a safe haven, counseling, and assistance with legal and social services, empowering the client to escape the abusive environment and access necessary resources for herself and potentially her children.
Choice C rationale
Paperwork needed to file a restraining order is a legal step that the client may choose to pursue later. However, in an immediate confiding situation, providing a direct safety resource like shelter information is more paramount, as filing a restraining order requires time and legal processes that may not offer immediate protection.
Choice D rationale
A safety plan to keep in a purse at all times is a valuable tool for future use but does not address the immediate need for a safe place or resources. While important for long-term safety, the initial intervention should focus on providing immediate pathways to escape the abusive situation.
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