Health Promotion and Maintenance
5. Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
Health Promotion and Maintenance
5. Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
. Call physician for oxygen saturations below 85%.
. Daily weights.
. Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
. Strict I&O.
. Enfamil formula ad lib.
Test-Taking Tip
Read the stem carefully. The question asks for the identification of orders that should not be implemented.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
. . .
Answer 1 is correct because the nurse should question an order that requires the nurse to call the physician for an oxygen saturation that is appropriate for an infant waiting surgical repair for a severe cyanotic heart defect. Answer 2 is incorrect because this is an appropriate order; the infant with a heart defect should be weighed daily to assist in monitoring fluid status. Answer 3 is correct because this parameter is too low. The heart rate should be at least 100 when administering digoxin (Lanoxin) to an infant. Answer 4 is incorrect because this is an appropriate order; the infant with a heart defect should have strict monitoring of intake and output (I&O). Answer 5 is correct because an infant with a congenital heart defect frequently requires formula with extra calories per ounce. Regular Enfamil formula would not provide sufficient calories.