A nurse is caring for an infant who has heart failure and a new prescription for digoxin.Which of the following findings should the nurse report to the provider?
Weight loss 0.25 kg (0.55 lb)
Vomiting twice in 4 hr
Respiratory rate 30/min
Heart rate 130/min
The Correct Answer is B
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Introducing fruit juice at 4 months old is not recommended because infants' digestive systems are not yet ready for such foods, and it can increase the risk of tooth decay and obesity.
B: Introducing eggs at 6 months could be appropriate; however, it is not the best choice as it does not reflect the gradual introduction of new foods one at a time, which is essential to monitor for any allergic reactions or food intolerances.
C: Offering cereal with a percent of milk is not advisable for a 4-month-old infant as cow's milk should not be introduced until the child is at least 12 months old due to the risk of iron deficiency and potential allergies.
D: Offering a new food every 7 days is the correct approach as it allows parents to introduce new foods gradually and monitor the infant for any adverse reactions or allergies, which aligns with the guidelines provided by health authorities.
Correct Answer is B
Explanation
Choice A reason:
Biting behavior in a 15-month-old child is developmentally appropriate and not indicative of child maltreatment.
Choice B reason:
Correct. A fracture resulting from a bicycle injury may raise concerns about the child's safety and supervision, and it should be reported for further evaluation.
Choice C reason:
A history of frequent urinary tract infections is a medical concern but does not necessarily indicate child maltreatment.
Choice D reason:
Small bruises on the shins are common in toddlers and are typically the result of normal play and exploration. They are not necessarily indicative of child maltreatment.
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