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?

Choice A Reason:

Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.

Choice B Reason:

Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.

Choice C Reason:

Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.

Choice D Reason:

Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.

Choice A Reason:

Keeping the infant in a visually stimulating environment might not directly address the nutritional or developmental needs of an infant with failure to thrive. While visual stimulation is essential for infant development, it's not the primary intervention for this condition.

Choice B Reason:

Assigning consistent nursing staff to care for the infant can provide stability and continuity, which can positively impact the infant's emotional well-being. However, this alone might not address the underlying issues related to failure to thrive.

Choice C Reason:

Giving the infant fruit juice between feedings might not be the best approach. Fruit juice can fill an infant's stomach without providing the necessary nutrients, potentially further reducing the intake of essential formula or breast milk.

Choice D Reason:

Using half-strength formula when feeding the infant isn't recommended without specific guidance from a healthcare provider. Diluting formula can compromise the infant's nutritional intake, potentially exacerbating the issue of failure to thrive.