A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

Answer and Explanation

The Correct Answer is ["90"]

The nurse should withhold the dose if the infant's apical heart rate is less than 90 beats per minute.

Digoxin is a medication that can slow the heart rate. If an infant's heart rate is already too slow, administering digoxin can increase the risk of bradycardia, a serious heart rhythm disturbance.

It's important to monitor the apical heart rate for a full minute before administering digoxin to an infant and to withhold the dose if the heart rate is below the specified threshold.

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Correct Answer is D

Explanation

A. "Newborns are abdominal breathers."
Explanation: While it is true that newborns primarily use their diaphragms for breathing (abdominal breathing), this statement does not specifically address why the respiratory rate should be counted for a full minute.
B. "Activity will increase the respiratory rate."
Explanation: This statement acknowledges that activity can influence the respiratory rate but does not specifically address the need to count for a full minute to capture the irregular patterns.
C. "Newborns do not expand their lungs fully with each respiration."
Explanation: This statement highlights a characteristic of newborn respiratory physiology but does not specifically explain the importance of counting the respiratory rate for a full minute.
D. "The rate and rhythm of breath are irregular in newborns."
Explanation:
Newborns often have irregular breathing patterns, and counting the respiratory rate for a full minute helps capture the variations in rate and rhythm accurately. Newborns may experience periods of rapid breathing followed by periods of slower breathing, and their respiratory patterns can be influenced by sleep-wake cycles, feeding, and other factors. Counting for a full minute provides a more comprehensive and representative assessment of the newborn's respiratory status.

A. Edema in the lower extremities B. Ascites C. Shortness of breath D. Hepatomegaly

Correct Answer is C

Explanation

A. Edema in the lower extremities:
Incorrect: Edema in the lower extremities is more characteristic of right-sided heart failure. In left-sided failure, pulmonary congestion is more prominent.
B. Ascites:
Incorrect: Ascites, or fluid accumulation in the abdominal cavity, is also more commonly associated with right-sided heart failure.
C. Shortness of breath:
Correct Answer: Left-sided congestive heart failure can lead to pulmonary congestion, resulting in difficulty breathing or shortness of breath. This is often observed as increased work of breathing, rapid breathing, or other signs of respiratory distress in infants.
D. Hepatomegaly:
Incorrect: Hepatomegaly, or enlargement of the liver, is another manifestation more commonly associated with right-sided heart failure.

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A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

Correct Answer is D

Explanation

The nurse is collecting data on a 2 month-old-child with left-sided congestive heart failure. Which clinical manifestation would support this diagnosis of left-sided congestive heart failure?

Correct Answer is C

Explanation

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