A nurse is collecting data from an infant who has heart failure and is taking digoxin. The nurse should identify which of the following findings as an indication of digoxin toxicity?
Edema
Jaundice
Purulent sputum
Bradycardia
The Correct Answer is D
A. Edema: Edema can occur with heart failure, but it is not specifically an indication of digoxin toxicity. Digoxin helps improve heart function and reduce edema, so it is not a direct sign of toxicity.
B. Jaundice: Jaundice may indicate liver dysfunction, but it is not a common sign of digoxin toxicity. Liver function issues can arise from various causes, but jaundice is not typically associated with digoxin toxicity.
C. Purulent sputum: Purulent sputum suggests an infection, such as pneumonia, and is not related to digoxin toxicity. This symptom requires further evaluation for respiratory infections, not digoxin-related issues.
D. Bradycardia: Bradycardia (a slow heart rate) is a classic sign of digoxin toxicity. Digoxin can slow the heart rate by affecting the electrical conduction system of the heart, and bradycardia is a key indicator of overdose or toxicity in infants and children taking this medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prolonged crying: Prolonged crying can occur after an immunization, especially in infants, but it is generally not an immediate cause for concern unless accompanied by other symptoms such as difficulty breathing or skin changes.
B. Temperature 37.7° C (99.9° F): A mild fever is a common side effect after immunizations and is usually not a cause for immediate concern. A temperature of 37.7°C (99.9°F) is within a normal range and typically resolves on its own.
C. Hives on the child's neck: Hives (urticaria) can indicate an allergic reaction, which could potentially be a serious response to the immunization. An allergic reaction requires immediate attention and intervention, as it may progress to more severe symptoms such as difficulty breathing or anaphylaxis.
D. Redness at the injection site: Redness at the injection site is a common and expected reaction following an immunization. It is generally not a cause for concern unless it is accompanied by severe swelling, pain, or other signs of infection.
Correct Answer is B
Explanation
A. A blood pressure of 95/58 mm Hg can be within an acceptable range for an infant and is not typically a cause for concern in a 2-month-old.
B. A respiratory rate of 18/min is abnormally low for a 2-month-old infant. Infants normally have a respiratory rate of about 30–60/min, and a low rate may indicate respiratory depression or other serious issues that should be reported promptly.
C. A temperature of 37.4° C (99.3°F) is within the expected range for an infant and does not indicate fever.
D. A heart rate of 160/min is within the normal range for a young infant, especially when awake or active.
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