A 3-month-old infant with ventricular septal defect (VSD) is admitted to the pediatric unit with signs of congestive heart failure. The infant is receiving digoxin and furosemide. Which nursing assessment finding requires the most immediate intervention?

Scenario: A 3-month-old infant with VSD and CHF on digoxin and furosemide.

• Apical Pulse Check: Auscultate the apical pulse for a full 60 seconds. The critical safety parameter is to withhold digoxin if the infant's pulse is below 90-100 bpm.
• Signs of Toxicity: Assess for early signs beyond bradycardia, including vomiting, poor feeding, and lethargy. In older children, visual disturbances may be reported.
• Electrolyte & Drug Review: Check recent potassium levels, as hypokalemia potentiates digoxin toxicity. Review concurrent medications, especially diuretics like furosemide which can cause potassium loss.

1. Withhold the Dose: Do not administer the scheduled digoxin.
2. Notify the Prescriber Immediately: Report the heart rate, any other signs of toxicity, and recent lab values.
3. Continuous Monitoring: Place the infant on a cardiorespiratory monitor to observe for worsening bradycardia or new arrhythmias.

• Daily Weights: Monitor strict intake and output and daily weights on the same scale to assess fluid balance. A sudden increase may indicate worsening CHF.
• Respiratory Status: Monitor respiratory rate, work of breathing, and oxygen saturation. Mild tachypnea and retractions are common with VSD and CHF.
• Caregiver Teaching: Educate parents to always check the infant's pulse before giving digoxin at home. Instruct them to call the provider if the pulse is below the specified threshold, if the infant vomits a dose, or shows signs of illness. Emphasize safe storage of digoxin to prevent accidental poisoning.