A child with a heart defect has been prescribed a maintenance dose of Lanoxin elixir at 0.07 mg/kg/day, divided into two doses.
The child weighs 19 pounds.
What is the maximum dose of medication the nurse should administer in each dose? T 0.3 mg.
Answer and explanation
The correct answer is Choice B, Choice C, Choice D.
Choice A rationale
A large bruise on the forehead of a 2-year-old could occur from accidental falls, which are common at this developmental stage due to increased mobility and decreased coordination. It does not necessarily suggest abuse unless accompanied by other suspicious findings.
Choice B rationale
Circular abrasions around the wrists are highly indicative of physical abuse as they suggest binding injuries. Restraining a child is neither acceptable nor normal, and such findings must be reported for further investigation by child protective services.
Choice C rationale
A burn on the palm of a 10-year-old’s hand raises concerns for abuse as accidental burns usually occur on accessible areas like arms or legs, not the palm. This pattern could indicate intentional infliction, requiring mandatory reporting to authorities.
Choice D rationale
Splash burns on the front torso in a 6-year-old are suspicious if inconsistent with the child’s developmental abilities or history provided by caregivers. Intentional scald burns often follow specific patterns, like splash marks, and must be reported for investigation.

Choice A rationale

Accurate measurement of intake and output is crucial after atrial septal defect repair to detect potential fluid imbalances or kidney dysfunction. Monitoring ensures early intervention in cases of dehydration or fluid overload.

Choice B rationale

Providing uninterrupted rest promotes recovery by minimizing stress on the cardiovascular system and reducing metabolic demands post-surgery. Adequate rest also allows tissue healing and stabilizes vital parameters.

Choice C rationale

Maintaining a thermoneutral environment prevents temperature fluctuations, which could increase metabolic demand and stress the healing heart. Temperature regulation is particularly important in infants with compromised cardiac function.

Choice D rationale

Encouraging bonding supports emotional and psychological recovery for both the infant and parents. Physical closeness can improve the infant's developmental outcomes and reduce parental anxiety after surgery.

Choice E rationale

Using an incentive spirometer 10 times hourly is not appropriate for infants. Incentive spirometers are designed for cooperative patients, typically older children or adults, as they require active participation in deep-breathing exercises.

Choice A rationale

A slurping or clicking sound indicates poor latching and is often associated with air entering the mouth due to improper seal or positioning of the infant. These sounds can reflect nipple misalignment or inadequate breast tissue placement into the infant's mouth, affecting milk transfer and leading to potential breastfeeding complications, such as nipple pain or reduced milk intake.

Choice B rationale

Audible swallowing confirms that the infant is successfully transferring milk and is properly latched. Proper latch allows efficient milk removal, which triggers swallowing reflexes. It reflects an absence of air entry and indicates that the infant is receiving milk without difficulty, promoting both nutritional intake and breastfeeding success.

Choice C rationale

The infant's tongue cupping under the breast with lips flanged ensures proper latch by creating a vacuum seal. This position prevents air leakage and allows effective milk transfer. Tongue cupping and lip flanging optimize compression of the lactiferous sinuses, supporting effective breastfeeding and minimizing discomfort for the mother.

Choice D rationale

Rhythmic sucking is a sign of coordinated latch and feeding. It reflects successful milk transfer and synchronization between suckling and swallowing. Rhythmic patterns reduce the risk of nipple trauma by ensuring proper placement and suction. This indicates that breastfeeding dynamics are efficient and beneficial.

Choice E rationale

Dimpling of the infant's cheeks occurs due to suction difficulties and often signifies improper latch or weak oral musculature. It leads to air leakage and insufficient milk removal. This finding may contribute to feeding inefficiencies and nipple trauma, indicating a need for latch correction.