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 ["A","B"]
Explanation
Pitocin and Methergine are both medications used to manage postpartum hemorrhage (PPH) by causing the uterus to contract and reduce bleeding. Pitocin is the most effective and preferred medication for PPH prevention and treatment.
Choice C is wrong because Terbutaline is a medication that relaxes the uterus and is used to stop preterm labor, not PPH.
Choice D is wrong because Hemabate is a brand name for carboprost, which is a prostaglandin that can be used for PPH, but it has more side effects and contraindications than Pitocin or Methergine.
Choice E is wrong because Magnesium sulfate is a medication that prevents seizures in women with preeclampsia or eclampsia, not PPH.
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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