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 A
Explanation
Choice A rationale:
This response indicates an understanding of the teaching about celiac disease. Rice is a gluten-free grain, which makes rice pudding a suitable dessert option for a child with celiac disease. Gluten is a protein found in wheat, barley, and rye, and individuals with celiac disease need to avoid gluten-containing foods.
Choice B rationale:
Barley is a gluten-containing grain, and feeding a child a barley-based breakfast cereal is not appropriate for someone with celiac disease. Gluten-containing grains can trigger adverse reactions in individuals with celiac disease due to their inability to properly digest gluten.
Choice C rationale:
Rye bread contains gluten, and making sandwiches using rye bread is not a suitable choice for a child with celiac disease. Gluten-free bread options, typically made from rice, corn, or other gluten-free flour, should be chosen instead.
Choice D rationale:
Chocolate malt may contain ingredients that could potentially contain gluten, and it's not a safe snack option for a child with celiac disease. Individuals with celiac disease need to be cautious about hidden sources of gluten in processed foods.
Correct Answer is B
Explanation
Choice A rationale:
Positioning the child sitting with their buttocks at the edge of the table is not appropriate for collecting a bone marrow specimen from a preschooler. This position does not provide adequate access to the bone marrow aspiration site and may lead to discomfort for the child.
Choice B rationale:
Placing the child in a prone position (lying face down) is suitable for collecting a bone marrow specimen from a preschooler. This position exposes the posterior iliac crest, which is a common site for bone marrow aspiration. It allows for easier access to the bone marrow and reduces the risk of injury.
Choice C rationale:
Positioning the child side-lying to expose the vertebrae is not the recommended position for bone marrow aspiration. The iliac crest, not the vertebrae, is the usual site for this procedure in children. Placing the child in a side-lying position would make it difficult to access the appropriate site.
Choice D rationale:
Placing the child supine with legs flexed outward into a frog-like position is suitable for collecting a bone marrow specimen. This position provides access to the iliac crest while allowing for better immobilization of the child. It also ensures the child's safety and comfort during the procedure.
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