47. A nurse notes that a 2-week-old infant with a cyanotic heart defect and mild congestive heart failure has an apical pulse rate of 100 beats/min. Which action should the nurse take?
47. A nurse notes that a 2-week-old infant with a cyanotic heart defect and mild congestive heart failure has an apical pulse rate of 100 beats/min. Which action should the nurse take?
. Withhold the digoxin because the heart rate is too low.
. Notify the pediatrician immediately.
. Administer the medication as scheduled.
. Retake the apical pulse in 1 hour.
Test-Taking Tip
The nurse should withhold the digoxin in an infant in this age group with this diagnosis when the heart rate is 100 beats per minute. Ask yourself: Is there a problem or not? And, if there is a problem, what steps and in what order should the nurse proceed?
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Interactions
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Answer 1 is correct because a normal heart rate for a 2-week-old infant is 120 to 160 beats per minute. A heart rate of 100 beats per minute is too low in a 2-week-old infant, and the digoxin should be withheld pending further assessment of the infant. Answer 2 is incorrect because it is too soon to notify the pediatrician. The nurse needs to further assess the infant and then notify the pediatrician if it is appropriate. Answer 3 is incorrect because a heart rate of 100 beats per minute is too low in a 2-week-old infant, and the digoxin should be withheld pending further assessment of the infant. Answer 4 is incorrect because the nurse should revalidate the initial assessment findings in 15 minutes, prior to proceeding with any additional interventions. If the infant's heart rate remains 100 beats per minute, the nurse should continue to withhold the medication and then notify the pediatrician.