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?
Administer cool, humidified oxygen via nasal cannula.
Provide less frequent, higher volume feedings.
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
The Correct Answer is A
Choice A rationale:
Administer cool, humidified oxygen via nasal cannula. Infants with heart failure often experience respiratory distress due to inadequate oxygenation. Administering cool, humidified oxygen via nasal cannula helps improve oxygen saturation and alleviate respiratory distress. Humidified oxygen prevents the mucous membranes from drying out, making breathing easier for the infant. Cool oxygen is preferred to reduce the work of breathing and to soothe irritated airways, improving the overall comfort of the infant.
Choice B rationale:
Provide less frequent, higher volume feedings. Infants with heart failure may have difficulty feeding due to fatigue and increased respiratory effort. Providing less frequent, higher volume feedings ensures that the infant receives adequate nutrition without becoming overly fatigued during feeding sessions. It allows the infant to obtain the necessary nutrients without putting excessive stress on their weakened cardiovascular system.
Choice C rationale:
Place the infant in a prone position. Placing the infant in a prone position is not recommended in the care of a child with heart failure. Placing the infant in an upright or semi-upright position is more appropriate as it reduces the workload on the heart and improves respiratory function. Placing the infant flat on their back may cause increased pressure on the diaphragm and worsen respiratory distress.
Choice D rationale:
Repeat a digoxin dosage if the infant vomits within 1 hr of administration. Digoxin is a medication commonly prescribed for heart failure. However, if the infant vomits shortly after receiving a dose, repeating the dose is not advisable. Vomiting may indicate that the medication was not properly absorbed, and administering an additional dose could lead to an overdose. Instead, the nurse should consult the healthcare provider for further instructions and closely monitor the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.
Choice B rationale:
Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.
Choice C rationale:
Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.
Choice D rationale:
Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.
Correct Answer is B
Explanation
The correct answer is choiceb. “We will place the diaper under the straps.”
Choice A rationale:
Adjusting the straps daily is not recommended.The straps should only be adjusted by a healthcare professional to ensure proper fit and effectiveness.
Choice B rationale:
Placing the diaper under the straps is correct.This helps to keep the harness clean and dry, and ensures that the straps remain in the correct position.
Choice C rationale:
The duration of wearing the Pavlik harness is typically longer than 2 weeks.It is usually worn for about 6-12 weeks, depending on the doctor’s recommendation.
Choice D rationale:
Applying lotion to the skin under the straps is not advised as it can cause skin irritation and affect the fit of the harness.
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