A nurse is assisting with the plan of care for an infant who has heart failure. Which of the following actions should the nurse recommend to include in the plan of care?
Ensure the infant bottle feeds for 45 min.
Administer digoxin for a pulse of 70/min.
Allow for frequent rest periods.
Maintain the infant in a supine position.
The Correct Answer is C
Choice A rationale:
Ensuring the infant bottle feeds for 45 minutes is not recommended for an infant with heart failure. Prolonged feeding sessions can lead to increased fatigue and stress on the infant's cardiovascular system, exacerbating the heart failure symptoms.
Choice B rationale:
Administering digoxin for a pulse of 70/min is not appropriate. Digoxin is commonly used in heart failure cases to improve cardiac contractility and reduce heart rate. However, giving digoxin solely based on the heart rate without considering other factors can lead to potential overdose and adverse effects.
Choice C rationale:
(Correct Choice) Allowing for frequent rest periods is crucial in the plan of care for an infant with heart failure. Infants with heart failure often experience fatigue and difficulty feeding due to compromised cardiac function. Allowing them to rest between activities helps conserve energy and supports their overall well-being.
Choice D rationale:
Maintaining the infant in a supine position is not the best choice for an infant with heart failure. While the supine position is recommended for safe sleep to reduce the risk of sudden infant death syndrome (SIDS), it may not be optimal for an infant with heart failure. An inclined position may be more suitable to alleviate potential respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"I should start by feeding my baby 3 tablespoons of solid food." At 6 months of age, infants are typically just beginning to transition to solid foods. Starting with 3 tablespoons of solid food might be overwhelming and inappropriate for the infant's digestive system. Introducing small amounts and gradually increasing the volume allows the infant to adapt to the new textures and flavors.
Choice B rationale:
"I should limit my baby to 8 ounces of juice per day." Juice consumption should be limited for infants. Juice offers little nutritional value and can contribute to excessive calorie intake, leading to potential weight gain and tooth decay. At 6 months, the primary source of nutrition should still be breast milk or formula, and the introduction of solid foods is meant to complement, not replace these sources.
Choice C rationale:
"I should introduce a new solid food to my baby every five to seven days." This statement indicates an understanding of the recommended approach for introducing solid foods to an infant. Introducing a new food every five to seven days allows the parent to monitor for any potential allergic reactions or sensitivities. This gradual approach helps identify specific foods that the infant may not tolerate well.
Choice D rationale:
"I should sweeten my baby's food with a teaspoon of honey." This statement is incorrect and potentially dangerous. Honey should not be given to infants under 12 months of age due to the risk of infant botulism, a serious and potentially fatal illness. Honey can contain spores of Clostridium botulinum bacteria, which can multiply and produce toxins in an infant's immature digestive system. It's important to avoid honey until the child is older to ensure their safety.
Correct Answer is A
Explanation
Choice A rationale:
Correct Choice. Current pregnancy is a contraindication to administering the measles, mumps, and rubella (MMR) vaccine. The MMR vaccine contains live attenuated viruses, and it is generally contraindicated during pregnancy due to the potential risk to the developing fetus. Pregnant individuals should wait until after giving birth to receive the MMR vaccine.
Choice B rationale:
Mild ear infection is not a contraindication to administering the MMR vaccine. Mild illnesses, such as mild upper respiratory infections or low-grade fevers, are not typically considered contraindications for vaccination. In fact, immunization might be recommended in these cases to ensure protection against preventable diseases.
Choice C rationale:
A family history of seizures is not a contraindication to administering the MMR vaccine. Seizures are not known to be associated with the MMR vaccine. Therefore, a family history of seizures would not preclude an individual from receiving the vaccine.
Choice D rationale:
Severe peanut allergy is not a contraindication to administering the MMR vaccine. Allergies, including severe peanut allergies, are not considered contraindications for the MMR vaccine. Only individuals with a known severe anaphylactic allergy to a vaccine component (such as gelatin or neomycin) would have a contraindication to receiving the vaccine.
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