What is the nurse's first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?

Choice A rationale:

The first dose of the immunization for Measles, mumps, and rubella (MMR) is typically given at the age of 1 year. This timing is in line with the recommendations from organizations like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Administering the MMR vaccine at this age ensures early protection against these contagious diseases. Delaying the vaccine could put the child at risk, especially considering the highly infectious nature of measles.

Choice B rationale:

Administering the MMR vaccine at 18 months is not in line with the recommended immunization schedule. Waiting until 18 months might expose the child to the risk of contracting these diseases during the gap period, as maternal immunity wanes after the first few months of life.

Choice C rationale:

Administering the MMR vaccine at 2 years is later than the recommended age. Waiting until 2 years could leave the child vulnerable to these diseases during the time between birth and the administration of the vaccine. Early immunization, starting at 1 year, provides essential protection during this critical period.

Choice D rationale:

Waiting until 4 years to administer the MMR vaccine is not in line with the standard immunization schedule. Delaying the vaccine until 4 years of age leaves the child susceptible to these diseases for a more extended period, which is not recommended for preventing outbreaks and ensuring community immunity. The first dose of the immunization for Haemophilus influenzae type B (Hib) is given at the age of 2 months.

Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.