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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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.
Correct Answer is B
Explanation
A way to establish rapport. Doing a simple magic trick using gauze is a way to gain the child’s trust and attention, and to make the dressing change less stressful and more fun. This is appropriate for a 5-year-old child who is in the stage of initiative versus guilt according to Erikson’s theory of psychosocial development.
Choice A is wrong because 5-year-old children are curious and imaginative, and they enjoy magic tricks and fantasy play.
Choice C is wrong because a simple magic trick is not too distracting, but rather a way to engage the child and reduce anxiety.
Choice D is wrong because a simple magic trick is not inappropriate due to the child’s cognitive development. According to Piaget’s theory of cognitive development, 5-year-old children are in the preoperational stage, which means they can use symbols and language to represent objects and events.
A magic trick using gauze is a symbolic representation of something else, which the child can understand and appreciate.
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