A nurse is assisting with the care of an infant who has heart failure. Which of the following actions should the nurse take?

Place the infant in a supine position during naps.

Feed the infant a bottle every 4 hr.

Document the infant's respiratory rate every 2 hr.

Withhold digoxin if the infant's heart rate is greater than 100/min.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Placing the infant in a supine position during naps might not be the best action for an infant with heart failure. In heart failure, infants often experience difficulty breathing due to fluid accumulation in the lungs. Placing the infant in a more upright position, such as semi-Fowler's, can help alleviate some of this respiratory distress.
Choice B rationale:
Feeding the infant a bottle every 4 hours is important, but it might not directly address the immediate concerns of an infant with heart failure. Infants with heart failure might have difficulty feeding due to fatigue and respiratory distress. Feeding smaller, more frequent meals and assessing the infant's feeding tolerance is crucial.
Choice C rationale:
Correct Answer. Documenting the infant's respiratory rate every 2 hours is an important action. Infants with heart failure often have respiratory distress and an increased respiratory rate, as the body tries to compensate for decreased cardiac output. Documenting the respiratory rate will help the healthcare team monitor the infant's condition and assess the effectiveness of interventions.
Choice D rationale:
Withholding digoxin if the infant's heart rate is greater than 100/min is not necessarily the correct action. Digoxin is a medication commonly used in heart failure to improve cardiac contractility. While it's important to monitor the infant's heart rate, a heart rate of greater than 100/min might be due to the body's compensatory mechanisms in response to heart failure. Withholding the medication without consulting a healthcare provider might not be appropriate.

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Correct Answer is A

Explanation

The answer is a. Hard-boiled egg.

Hard-boiled eggs are a safe snack for a toddler.They are soft, easy to chew, and rich in nutrients.

Now, let’s discuss why the other options are not recommended:

b. Grapes: Whole grapes are not recommended for toddlers due to the risk of choking.They are round and slippery, making them difficult for toddlers to chew properly.

c. Raw carrots: Similar to grapes, raw carrots pose a choking hazard for toddlers.They are hard and can break into large pieces that might block a toddler’s airway.

d. Popcorn: Popcorn is not safe for toddlers. The kernels can get stuck in a toddler’s throat and cause choking.Moreover, unpopped or partially popped kernels are hard and can also pose a choking risk.

A. A 6-month-old infant who has a spiral fracture to a lower extremity. B. A 9-month-old infant who has been exposed to bedbugs and has cellulitis. C. A 4-year-old preschooler who has a rivalry with their siblings. D. A 24-month-old toddler who experiences occasional incontinence.

Correct Answer is A

Explanation

Choice A rationale:
The nurse should report the finding of a 6-month-old infant with a spiral fracture to a lower extremity to local authorities. Spiral fractures in infants, especially those who are not yet independently mobile, raise concerns about possible child abuse or non-accidental trauma. The unique pattern of spiral fractures is often associated with twisting forces, which are unlikely to occur accidentally in infants who cannot perform such movements. Reporting such cases is essential to ensure the safety and well-being of the child.
Choice B rationale:
A 9-month-old infant exposed to bedbugs and cellulitis is not an emergency that requires reporting to local authorities. While cellulitis can be serious, it is not an immediate threat to the child's safety, and the focus should be on providing appropriate medical care.
Choice C rationale:
A 4-year-old preschooler with rivalry among siblings does not indicate a need for reporting to local authorities. Sibling rivalry is a common occurrence in families and does not pose a threat to the child's safety. It is a social and developmental issue that can be addressed within the family.
Choice D rationale:
A 24-month-old toddler experiencing occasional incontinence does not require reporting to local authorities. Occasional incontinence can be a normal part of toddler development as they learn to control their bladder. It does not indicate abuse or immediate danger to the child.

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