A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr. of administration.
Administer cool, humidified oxygen via nasal cannula
Provide less frequent, higher volume feedings
The Correct Answer is C
Choice A Reason:
Placing the infant in a prone position might not be suitable for an infant with heart failure. Typically, an upright or semi-upright position can help reduce the workload on the heart by improving respiratory function and aiding in cardiac output.
Choice B Reason:
Repeating a digoxin dosage if the infant vomits within 1 hour of administration isn't recommended without consulting a healthcare provider. If vomiting occurs within this time frame, giving another dose might result in overdosing.
Choice C Reason:
Administering cool, humidified oxygen via nasal cannula can be beneficial for an infant with heart failure, as it helps in providing supplemental oxygen and maintaining adequate oxygenation levels.
Choice D Reason:
Providing less frequent, higher volume feedings might not be appropriate for an infant with heart failure. These infants often require smaller, more frequent feedings to prevent overloading the digestive system and to manage fluid intake.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A Reason:
Heat the formula to 39°C (102°F) prior to administration. Formula temperature should be warm, but heating it to a specific temperature like 39°C (102°F) is not typically necessary. Room temperature or slightly warm formula is often suitable.
Choice B Reason:
The supine position (lying flat on the back) is not recommended during enteral feedings. Infant should be placedin a semi-upright position (usually around 30 to 45 degrees)- this helps prevent aspiration and aids in proper digestion and passage of the feeding into the stomach.
Choice C Reason:
Offer the infant a pacifier during feedings. Offering a pacifier during enteral feedings could potentially interfere with the feeding process and may increase the risk of aspiration. It's generally not recommended during tube feedings.
Choice D Reason:
Instill the formula over a period of 30 to 45 minutes. Slowly administering the formula over this duration allows for proper digestion and reduces the risk of feeding-related complications.
Choice E Reason:
Check for residual volumes by aspirating stomach contents. Checking for residual volumes helps ensure the stomach is adequately emptying and can help prevent complications such as aspiration or feeding intolerance.
Correct Answer is C
Explanation
Choice A Reason:
"We will apply lotion to the skin under the straps." Applying lotion under the straps might create moisture, interfere with the harness's function, or cause skin irritation. It's generally recommended to avoid lotions or creams under the straps.
Choice B Reason:
"We should expect our baby to wear this harness for 2 weeks." The duration for wearing a Pavlik harness can vary significantly depending on the severity of the hip dysplasia and the infant's response to treatment. The duration is determined by the healthcare provider's assessment and may extend beyond 2 weeks.
Choice C Reason:
"We will place the diaper under the straps." Placing the diaper under the straps helps prevent skin irritation and chafing caused by the straps rubbing against the skin. It ensures that the skin remains protected and reduces the risk of skin breakdown or discomfort for the infant.Pavlik harnesses are typically designed to keep the hips in a specific position, and diapers should be placed underneath to avoid leaks soiling the harness
Choice D Reason:
"We should adjust the straps daily." Adjusting the straps of a Pavlik harness should only be done by a healthcare professional to ensure proper positioning and safety.
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