# A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriate regarding assessing apical pulse and withholding the dose if signs of toxicity occur?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391746&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriate regarding assessing apical pulse and withholding the dose if signs of toxicity occur?

## Option

1. "Valproate has the highest teratogenic risk of all anticonvulsants — neural tube defects and developmental delay. Urgent consult with neurology and obstetrics is essential." **✔ Correct answer**
2. "Valproate is a known teratogen; immediate discontinuation is necessary, and starting fluoxetine 20 mg daily is a safe alternative for mood stabilization during pregnancy."
3. "Valproate exposure in the first trimester is associated with minor malformations that resolve spontaneously; the critical period for neural tube defects starts at 20 weeks."
4. "The risk of bipolar relapse during pregnancy outweighs the teratogenic risk of valproate; continue the current dose and monitor drug levels monthly."

**Correct answer: 1**

## Explanation

When administering Digoxin, key nursing considerations include monitoring patient status, checking critical laboratory values, and providing appropriate safety education. Unsafe practices such as stopping medications abruptly or doubling missed doses are incorrect.

## In-depth explanation

Memory Tip Valproate = anticonvulsant most toxic to fetus. Avoid in any woman of reproductive age unless absolutely no alternative AND on robust contraception. Folate ≥4 mg/day if exposure unavoidable.

## Clinical scenario

Scenario 28-year-old female on valproate 1000 mg/day for bipolar disorder. Pregnancy test positive at 6 weeks gestation. Stable on current regimen.

## Key concepts

- **Neural tube defect** — Failed closure of the neural tube (spina bifida, anencephaly); occurs by week 4-5; valproate is one of the strongest teratogenic drugs.
- **Teratogenic risk** — Probability of fetal malformation from in-utero exposure; valproate is among the highest of all medications.
- **Anticonvulsant in pregnancy** — Safer alternatives include lamotrigine and levetiracetam; phenytoin and carbamazepine carry intermediate risk; valproate and topiramate are highest risk.

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