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?

Rationale for Correct Choices:

• Fontanel finding: The sunken fontanel indicates signs of dehydration, which is the primary concern for this infant. Dehydration can lead to severe complications and should be addressed first through appropriate fluid resuscitation (IV fluids) to prevent further deterioration.
• Temperature: The infant has a fever of 38.4°C (101.1°F), which needs to be managed with acetaminophen as prescribed. While dehydration is the priority, the temperature should also be controlled to prevent worsening of the infant's condition and to make the child more comfortable.

Rationale for Incorrect Choices:

• Diaper area: While the excoriated diaper area is concerning, it is not the most urgent issue compared to dehydration, which can quickly worsen. Dehydration and fever management should be prioritized before addressing skin irritation.
• Stool culture results: The positive stool culture for Shigella is important for determining the infection, but addressing the infant's hydration status and fever is more urgent to stabilize the child. The results will guide further treatment but do not need immediate intervention over dehydration.
• Appetite history: While the infant's poor feeding history is significant, addressing dehydration and fever management should take precedence to stabilize the infant before evaluating feeding patterns in more detail.
• Activity tolerance finding: The infant’s fatigue is likely due to dehydration and fever. Stabilizing hydration and controlling the fever will improve the infant’s activity tolerance, making this secondary to the more urgent issues.

A. Maintain the child in a supine position: The child should not be in a supine (lying flat) position during enteral feedings, as this increases the risk of aspiration. The child should be positioned upright or at least 30 to 45 degrees to reduce this risk.
B. Discard gastric residuals prior to each feeding: While it is important to check gastric residuals before each feeding to ensure proper gastric emptying, residuals should not automatically be discarded. Depending on the volume of residuals, the feeding may need to be delayed or adjusted rather than discarded.
C. Warm the feeding in the microwave oven for 15 seconds: Feeding should never be warmed in the microwave because it can cause uneven heating, which could lead to burns. Feedings should be warmed using a safe method, such as a warm water bath, to ensure even temperature.
D. Administer the feeding to the child at 10 mL/min: Administering the feeding at a slow and controlled rate, such as 10 mL/min, is recommended to prevent discomfort and reduce the risk of aspiration. This rate allows the digestive system to process the feeding properly.