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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Increased expectoration is correct. Increased expectoration (coughing up and clearing mucus) could indicate improved airway clearance, which is a primary goal of chest physiotherapy in cystic fibrosis. Effective therapy would facilitate the removal of mucus from the airways, making it easier for the child to clear secretions.
Choice B Reason:
Reduced pain is incorrect. While reducing pain is important for overall comfort, chest physiotherapy's primary goal in cystic fibrosis is to improve airway clearance and lung function. Pain reduction might not be the primary indicator of the therapy's effectiveness in this context.
Choice C Reason:
Increased heart rate is incorrect. An increased heart rate might not directly indicate the effectiveness of chest physiotherapy for cystic fibrosis. The focus is primarily on improving respiratory function and airway clearance rather than affecting heart rate.
Choice D Reason:
Increased urine output is incorrect. Increased urine output is not typically a direct indicator of the effectiveness of chest physiotherapy in cystic fibrosis. Chest physiotherapy aims to improve respiratory function rather than affecting urine output.
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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