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, what action should the PN take?
Explanation & Rationale
A. A heart rate of 120 beats/minute in a 2-month-old infant is within the expected normal range, so there is no immediate need to alert the charge nurse. Routine findings should be documented and managed according to standard protocol. B. Digoxin should be withheld in infants if the apical heart rate is below 90–110 beats/minute depending on age. Since the infant’s heart rate is within the normal range, withholding the medication is not indicated. C. Digoxin can be safely administered because a heart rate of 120 beats/minute is appropriate for a 2-month-old infant. Documenting the heart rate ensures accurate recording of the assessment prior to administration and supports safe medication practice. D. There is no indication to delay or recheck the heart rate in 1 hour because the current rate is within normal limits. Delaying medication could interfere with therapeutic management.