How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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

A.

Place the infant in a supine position during naps.

B.

Feed the infant a bottle every 4 hr.

C.

Document the infant's respiratory rate every 2 hr.

D.

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. 
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Answer: B. Reposition the probe every 2 hours.

Rationale:

  • A. Warm the skin prior to probe placement:While cold fingers can lead to inaccurate readings,warming the skin is not an essential step and is not routinely recommended in clinical practice.
  • B. Reposition the probe every 2 hours:This iscorrect.Continuous pressure from the probe in one spot can cause skin breakdown and pressure injuries.Repositioning the probe every 2 hours helps to prevent this and ensure accurate readings.
  • C. Tape the wire to the palm of the hand:This is incorrect.The pulse oximeter probe should be placed on a vascular site,such as a fingertip or earlobe.Taping the wire to the palm would not provide accurate readings.
  • D. Apply the sensor to the index fingernail:This is incorrect.The fingernail does not have sufficient blood flow for accurate pulse oximetry readings.The probe should be placed on the fleshy pad of the fingertip.

Therefore, the most important action for the nurse to take is to reposition the probe every 2 hours to prevent skin breakdown and ensure accurate readings.

Additional Points:

  • The nurse should also choose a clean and dry site for probe placement.
  • The probe should be snug but not too tight.
  • The nurse should monitor the child for signs of skin breakdown,such as redness,swelling,or pain.
  • If the child is restless or active,the nurse may need to secure the probe with additional tape or a special wrap.

Correct Answer is B

Explanation

The correct answer is choiceb. “Your baby will be placed in elbow restraints following surgery.”

Choice A rationale:

Giving a pacifier to a baby after cleft lip surgery is generally not recommended as it can put pressure on the surgical site and potentially disrupt the healing process.

Choice B rationale:

Elbow restraints are used to prevent the infant from touching or rubbing the surgical site, which helps in protecting the stitches and ensuring proper healing.

Choice C rationale:

Infants are usually allowed to have fluids by mouth soon after surgery, often within a few hours, to ensure they stay hydrated and to monitor their ability to swallow.

Choice D rationale:

Positioning the baby on their abdomen is not recommended as it can put pressure on the surgical site.Instead, the baby should be positioned on their back or side to avoid any pressure on the repaired lip

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register