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 C
Explanation
Choice AReason:
Chocolate milk is incorrect. Similar to ice cream, chocolate milk is dairy-based and may have a thicker consistency, potentially causing discomfort or irritation to the throat.
Choice B Reason:
Sugar-free cherry gelatin-Avoid red, purple, or brown liquids, which simulate the appearance of blood if the child vomits.
Choice CReason:
Although the flavor might be a bit acidic, lime-flavored ice pops are generally clear or light in color and less likely to obscure bleeding. They are also soothing and can help with hydration
Choice D Reason:
Vanilla ice cream is incorrect. While ice cream might seem soothing, it's dairy-based and can coat the throat, potentially causing discomfort or mucus production, which may not be ideal for the healing process.
Correct Answer is B
Explanation
Choice A Reason:
Hyperactive reflexes are incorrect. Gasoline inhalation tends to affect the central nervous system and might result in CNS depression rather than hyperactivity, so hyperactive reflexes are less likely.
Choice B Reason:
Ataxia is correct.
Ataxia, which refers to a lack of muscle coordination or unsteady movements, can be an expected finding in individuals who have inhaled gasoline fumes. Gasoline inhalation can affect the nervous system, leading to symptoms like ataxia, dizziness, confusion, and unsteady gait.
Choice C Reason:
Hypothermia is incorrect. Gasoline inhalation is not typically associated with hypothermia. Inhaling gasoline vapors might cause respiratory irritation or CNS effects but not hypothermia.
Choice D Reason:
Pinpoint pupils is incorrect. Pinpoint pupils are more commonly associated with opioid use or certain medications affecting the nervous system. Gasoline inhalation is not typically associated with this pupil reaction.
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