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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Extremities warm to the touch. This manifestation is not indicative of decreased cardiac output. Warm extremities suggest adequate peripheral perfusion and circulation. In a child with decreased cardiac output, the body might attempt to shunt blood away from the extremities to prioritize vital organs, leading to cooler extremities.
Choice B rationale:
Capillary refill 2 seconds. A capillary refill time of 2 seconds is within the normal range for a preschool-aged child. This quick capillary refill suggests adequate circulation and is not a sign of decreased cardiac output. Prolonged capillary refill time might be indicative of poor peripheral perfusion.
Choice C rationale:
Blood pressure 112/66 mm Hg. While a blood pressure of 112/66 mm Hg might be within the normal range for a preschooler, it is not the most reliable indicator of decreased cardiac output. Blood pressure can be influenced by various factors, and a seemingly normal blood pressure does not rule out decreased cardiac output if other manifestations are present.
Choice D rationale:
Diminished pulses. This is the correct choice. Diminished or weak pulses are indicative of decreased cardiac output. Inadequate blood volume being pumped by the heart can lead to reduced peripheral perfusion, resulting in diminished pulses. This sign is important in assessing the child's cardiovascular status postoperatively, especially after a corrective procedure for tetralogy of Fallot.
Correct Answer is A
Explanation
Choice A rationale:
Pain following range-of-motion exercises is a significant finding that should be reported to the provider. It could indicate the possibility of complications, such as further injury or impaired healing. Adolescents with fractured bones are often encouraged to perform range-of-motion exercises to prevent stiffness and promote circulation. However, increased pain during or after these exercises could indicate problems like muscle strain or improper alignment of the fracture, which need to be addressed promptly.
Choice B rationale:
Pruritus (itching) under the cast is common and can be expected due to the accumulation of dead skin cells and sweat. While it can be uncomfortable for the client, it's not an urgent concern that requires immediate reporting to the provider. Strategies to alleviate itching, such as using a cool blow dryer under the cast, can be taught to the client.
Choice C rationale:
The presence of swelling while the extremity is dependent is a normal response to gravity and is not an alarming finding. Swelling when the extremity is dependent is expected, especially within the initial stages of fracture healing. It suggests that the blood supply is reaching the area for healing purposes. Elevation and rest can help reduce the swelling.
Choice D rationale:
Coolness of the toes could be due to reduced blood flow, but this finding alone may not be an immediate concern. It's essential to consider the client's overall circulation, capillary refill, and presence of pulses. If other signs of impaired circulation, such as pallor or delayed capillary refill, are present along with coolness, it might indicate compromised vascular supply. However, based on the information provided, this choice is not as urgent as reporting pain following range-of-motion exercises.
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