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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct answer is choice A. This action is crucial to ensure accurate capillary blood glucose testing. Allowing the skin antiseptic to dry before puncturing the child's finger helps prevent contamination of the blood sample, which can lead to inaccurate results. Wet antiseptic can dilute the blood sample and affect the glucose reading.
Choice B rationale:
This choice is incorrect because placing a cool washcloth on the child's finger is not standard practice before capillary blood glucose testing. While warmth can help increase blood flow and make the puncture process more comfortable, using a cool washcloth is not recommended, as it may constrict blood vessels and make it harder to obtain a sufficient blood sample.
Choice C rationale:
This choice is incorrect because testing the first drop of blood obtained after puncturing the child's finger is not recommended. The first drop of blood can be diluted with interstitial fluid and may not provide an accurate glucose reading. It's important to wipe away the first drop and use the subsequent drop of blood for testing.
Choice D rationale:
This choice is incorrect because puncturing the center of the pad of the child's index finger is not the recommended site for capillary blood glucose testing. The sides of the fingertip contain an adequate blood supply and are less painful for the child. Puncturing the center of the fingertip can be more painful and may not yield a sufficient blood sample.
Correct Answer is A
Explanation
Choice A rationale:
This statement reflects an accurate understanding of varicella (chickenpox) transmission and infection control. The lesions of varicella contain the virus and are contagious until they have crusted over. Allowing the child to go to the playroom only after the lesions have crusted helps prevent the spread of the virus to other individuals.
Choice B rationale:
This statement is incorrect because waiting for the crusts to fall off the lesions before bathing the child is not necessary. In fact, keeping the lesions clean and maintaining proper hygiene through gentle bathing can help prevent secondary bacterial infections.
Choice C rationale:
This statement is incorrect because bedrest for 3 days is not necessary for a child with varicella. While it's important to minimize contact with others during the contagious phase, physical activity can be gradually resumed as long as the lesions have crusted to prevent transmission.
Choice D rationale:
This statement is incorrect. Once a person has had chickenpox (varicella), they develop immunity to the virus and do not need to wear a mask when visiting someone with active varicella. This is because they are already immune to the virus due to their prior infection.
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