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.

Answer and Explanation

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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Correct Answer is B

Explanation

The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.

Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.

Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.

Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.

Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.

Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.

Normal ranges for pulse oximetry are 95% to 100%, for heart rate, are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.

A. Kimberly and Amanda sharing clay to each make things B. Brian playing with his truck next to Kristina playing with her truck. C. Adam playing a board game with Kyle, Steven, and Erich D. Danielle playing with a music box on her mother’s lap E. Danielle playing with a music box on her mother’s lap.

Correct Answer is B

Explanation

Brian playing with his truck next to Kristina playing with her truck. This is because parallel play is when children play side by side with similar toys but do not interact with each other. Parallel play is typical for toddlers and preschoolers.

Choice A is wrong because Kimberly and Amanda sharing clay to each make things is an example of cooperative play, which involves sharing, taking turns, and following

rules. Cooperative play is typical for school-age children.

Choice C is wrong because Adam playing a board game with Kyle, Steven, and Erich is also an example of cooperative play, as they are playing by the same rules and interacting with each other.

Choice D is wrong because Danielle playing with a music box on her mother’s lap is an example of solitary play, which is when a child plays alone and does not seek contact with others. Solitary play is typical for infants.

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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?

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Explanation

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Explanation

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