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?
Explanation & Rationale
A. Hold the medication and recheck the heart rate in 1 hour: Withholding digoxin is indicated if the infant’s heart rate is below the recommended threshold (usually <90–110 bpm for infants). A heart rate of 120 bpm is above this limit, so holding the dose is unnecessary. B. Administer the medication and document the heart rate: A heart rate of 120 bpm is within the safe range for a 2-month-old infant. Administering digoxin and documenting the cardiac assessment is appropriate, ensuring ongoing monitoring for therapeutic effect and potential toxicity. C. Administer the medication and alert the charge nurse: Since the heart rate is within normal limits, notifying the charge nurse is not required. Routine documentation and monitoring are sufficient. D. Hold the medication and document cardiac assessment: Holding digoxin when the heart rate is appropriate may compromise therapeutic management of heart failure. Documentation alone is insufficient without administering the prescribed dose.