A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.

b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.

Choice A reason:

Natural loss of deciduous teeth is incorrect. Natural loss of deciduous teeth, also known as baby teeth, usually begins around the age of 5 or 6 years. At the age of 2, a toddler would still have their baby teeth.

Choice B reason:

This is a normal finding in toddlers. It is common for toddlers to have a protruding abdomen due to their body composition and the normal development of their abdominal muscles.

Choice C reason:

Head circumference exceeds chest circumference: In a typical 2-year-old toddler, the head circumference should be less than the chest circumference. The head grows rapidly during infancy and slows down as the child grows older, leading to a cage in the head-to-chest ratio.

Choice D reason:

The fontanels, or soft spots on the skull, usually close by the end of the first year. By age 2, the fontanels should be closed or very close to being closed, and they would not typically be palpable.