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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The parents should notify the physician if the infant has a temperature above 37.7° C (100° F), new frequent coughing, or turning blue or bluer
than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.
Choice A is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.
Choice B is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.
Correct Answer is ["B","C"]
Explanation
The child’s care should include adequate hydration and pain management. The management of an acute event of a vaso-occlusive crisis is the use of potent analgesics (opioids), rehydration with normal saline or Ringer’s lactate, treatment of malaria (whether symptomatic or not) using artemisinin combination therapy, and the use of oxygen via face mask, especially for acute chest syndrome.
Choice A is wrong because correction of acidosis is not a specific intervention for the vaso- occlusive crisis.
Acidosis may occur as a complication of sickle cell disease, but it is not the primary cause of the crisis.
Choice D is wrong because the administration of heparin is not recommended for the vaso-occlusive crisis.
Heparin is an anticoagulant that may increase the risk of bleeding and does not prevent or treat the sickling process.
Normal ranges for hemoglobin are 11.5 to 15.5 g/dl for children after 2 years of age.
Normal ranges for reticulocyte count are 0.5% to 1.5% for adults and 0.5% to 2.5% for children.
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