A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Administer a half dose now.

Give another dose.

Mix the next dose with food.

Withhold this dose.

Answer and Explanation

The Correct Answer is D

Choice A: Administering a half dose now is not advisable, because it may result in underdosing or overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a partial dose may not achieve therapeutic levels or may exceed safe levels.

Choice B: Giving another dose is not advisable, because it may result in overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a full dose may exceed safe levels and cause adverse effects such as nausea, vomiting, bradycardia, arrhythmias, or visual disturbances.

Choice C: Mixing the next dose with food is not advisable, because it may affect the absorption and bioavailability of digoxin. Digoxin should be taken on an empty stomach or at least one hour before or two hours after meals, because food can interfere with its absorption from the gastrointestinal tract and reduce its effectiveness.

Choice D: Withholding the dose is the safest option. If vomiting occurs within 30 minutes of administration, it’s generally advised to skip that dose to avoid the risk of overdose. The next dose should be given as scheduled Digoxin has a long half-life and accumulates in tissues, so missing one dose will not significantly affect its therapeutic effect. Withholding this dose will avoid overdosing and toxicity of digoxin, which can be life-threatening in infants and children. The nurse should also advise the mother to resume the regular dosing schedule and monitor the infant's pulse rate and signs of digoxin toxicity.

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Correct Answer is B

Explanation

Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.

Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.

Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.

A. Keep the bed in the lowest position and initiate seizure and fall precautions. B. Place an indwelling urinary catheter and measure strict intake and output. C. Maintain elevated positioning of the dependent joints on affected side. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

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A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

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