What 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?
a. Weigh the infant every day on the same scale at the same time.
b. Notify the physician when weight gain exceeds more than 20 g/day.
c. Put the infant in a car seat to minimize movement.
d. Administer digoxin (Lanoxin) as ordered by the physician.
A
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A Excess fluid volume may not be overtly visible. Weight changes may indicate
fluid retention. Weighing the infant on the same scale at the same time each day
ensures consistency.
B An excessive weight gain for an infant is an increase of more than 50 g/day.
C With fluid volume excess, skin will be edematous. The infant's position should
be changed frequently to prevent undesirable pooling of fluid in certain areas.
D Lanoxin is used in the treatment of congestive heart failure to improve cardiac
function. Diuretics will help the body get rid of excess fluid.
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