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.
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
Provide less frequent, higher volume feedings.
The Correct Answer is A
Infants with heart failure often present with breathing trouble1, and administering oxygen can help improve oxygen delivery.
Choice B is wrong because placing an infant in a prone position does not help with heart failure.
Choice C is wrong because if an infant vomits within 1 hour of administration of digoxin, the dosage should not be repeated without consulting a healthcare provider.
Choice D is wrong because infants with heart failure may have feeding issues and providing less frequent, higher volume feedings may not be helpful34.
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Correct Answer is A
Explanation
The first action the nurse should take is to elevate the child’s leg.
This is choice A. Elevating the child’s leg can help reduce swelling and improve circulation.
After elevating the child’s leg, the nurse can then administer pain medication (choice B), petal the edges of the cast (choice C), and teach the child about cast care (choice D).
Correct Answer is A
Explanation
An allergy to neomycin is a contraindication for receiving the MMR vaccine.
Choice Bis wrong because a family history of seizures is not a contraindication for receiving the MMR vaccine.
Choice Cis wrong because an upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine.
Choice Dis wrong because a temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine.
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