A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.

Which of the following findings is the nurse's priority?

Negative doll's eye reflex

Sunken anterior fontanel

Potassium 5.1 mEq/L

Heart rate 162/min

Answer and Explanation

The Correct Answer is D

A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.

B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.

C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.

D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F"]

No explanation

A. Avoid removing the cream prior to the procedure. B. Gently rub the cream into the skin. C. Wash the site with alcohol prior to applying the cream. D. Apply the cream 1 hr before the procedure.

Correct Answer is D

Explanation

A. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.

B. The medication should applied repeatedly to provide analgesia

C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.

D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.

View Question and Answer

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A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide. Which of the following findings is the nurse's priority?

Nursing Test Bank

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Correct Answer is ["A","B","C","D","E","F"]

A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.

Which of the following findings is the nurse's priority?