Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?
Weigh the infant every day on the same scale at the same time.
Notify the physician when weight gain exceeds more than 20 g/day.
Put the infant in a car seat to minimize movement.
Administer digoxin as ordered by the physician.
The Correct Answer is D
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Choice A is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
Choice B is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
Choice C is wrong because putting the infant in a car seat to minimize movement may worsen the respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Perinatal transmission of HIV is when HIV is passed from a woman with HIV to her child during pregnancy, childbirth, or breastfeeding.
Breast milk from an infected mother can contain HIV and infect the baby.
Choice A is wrong because HIV can be transmitted at any stage of pregnancy, not only in the third trimester.
Choice B is wrong because needlestick injury is not a common mode of perinatal transmission of HIV. It is more likely to occur among health care workers who are exposed to contaminated needles or sharp objects.
Choice C is wrong because HIV can also be transmitted through the ingestion of amniotic fluid, but it is not the only way. Amniotic fluid is the fluid that surrounds and protects the baby in the womb.
Correct Answer is D
Explanation
This is because toddlers continue to have the short, straight internal ear canal of infants.
The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections.
Choice A is wrong because respirations are abdominal. This does not affect the susceptibility to infection.
Choice B is wrong because pulse and respiratory rates are slower than those in infancy. This also does not affect the susceptibility to infection.
Choice C is wrong because defense mechanisms are less efficient than those during
infancy. This is not true, as the defense mechanisms are more efficient compared with those of infancy.
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