The nurse is auscultating a 6-month-old client’s apical heart rate before giving a dose of digoxin and notes that the heart rate is 89 beats per minute. Which action should the nurse take?

Choice A reason: A heart rate of 89 beats per minute in a 6-month-old (normal 90–160) is low, indicating potential digoxin toxicity or decreased cardiac output. Withholding digoxin and assessing for symptoms like nausea or arrhythmias is critical to prevent harm, making this the correct action for the nurse. Choice B reason: Withholding digoxin and re-evaluating in 4 hours delays necessary assessment for toxicity or cardiac compromise in a 6-month-old with a low heart rate (89 bpm). Immediate evaluation is needed, making this incorrect, as it risks missing critical signs of digoxin-related complications. Choice C reason: Administering half the digoxin dose is unsafe without confirming the cause of the low heart rate (89 bpm). In infants, this could worsen toxicity or bradycardia. Withholding and assessing for toxicity is safer, making this an incorrect action for managing potential digoxin complications. Choice D reason: A heart rate of 89 bpm is below normal for a 6-month-old (90–160 bpm), and administering digoxin risks worsening bradycardia or toxicity. Normal infant heart rates are higher, making this incorrect, as the nurse must withhold the dose and assess for complications.