Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant’s heart rate is 120 beats/minute. Based on this finding, which action should the PN take?
A.
Hold the medication and recheck the heart rate in l hour.
B.
Administer the medication and document the heart rate.
C.
Administer the medication and alert the charge nurse.
D.
Hold the medication and document cardiac assessment.
The Correct Answer and Explanation is:
The correct answer is:
B. Administer the medication and document the heart rate.
Explanation:
Digoxin (Lanoxin) is a cardiac glycoside commonly used in infants and children to treat conditions like heart failure and certain arrhythmias. It works by increasing the force of the heart’s contractions and slowing down the heart rate, improving cardiac output.
Before administering digoxin, it is critical to assess the heart rate, as digoxin can cause bradycardia (a slow heart rate). The heart rate threshold at which digoxin is held varies depending on the age of the child:
- For infants, the typical guideline is to hold the medication if the heart rate is below 100 beats per minute.
- For older children, the cutoff may be lower, such as 70 to 80 beats per minute.
In this scenario, the 2-month-old infant’s heart rate is 120 beats per minute, which is within the normal range for infants of this age (normal heart rate range for infants 1-3 months is between 100 and 160 beats per minute). Since the heart rate is above the threshold of 100 beats per minute, it is safe to administer the medication.
The practical nurse (PN) should administer the digoxin and document the heart rate in the medical record. Documentation is essential as it provides a legal record and helps monitor the infant’s response to the medication. If the heart rate had been lower than 100 beats per minute, the correct action would have been to hold the medication and notify the healthcare provider.
In cases where bradycardia or other concerning symptoms arise, further evaluation by the healthcare team is necessary. However, since the heart rate is normal and the infant is not showing signs of distress, the PN can proceed with administration without the need to notify the charge nurse.