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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Roseola infantum is a common viral illness in infants and young children, but it is not considered a notifiable infectious disease.
Choice B reason:
Correct. Measles is a notifiable infectious disease. This means that healthcare providers are required to report any diagnosed cases to public health authorities due to its potential for outbreaks.
Choice C reason:
Fifth disease, caused by parvovirus B19, is typically a mild viral illness in children and is not classified as a notifiable infectious disease.
Choice D reason:
Scabies is a parasitic infestation, not an infectious disease. It is caused by the Sarcoptes scabiei mite and is not considered notifiable.
Correct Answer is D
Explanation
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
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