# A 6-month-old infant with congenital heart failure is admitted to the pediatric unit. The infant is receiving digoxin 0.025 mg PO daily and furosemide 10 mg PO twice daily. During the morning assessment, the nurse notes the infant is lethargic, has vomiting, and the apical heart rate is 92 beats per minute. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541939 > language: ko > subject: Child Health ## 문제 A 6-month-old infant with congenital heart failure is admitted to the pediatric unit. The infant is receiving digoxin 0.025 mg PO daily and furosemide 10 mg PO twice daily. During the morning assessment, the nurse notes the infant is lethargic, has vomiting, and the apical heart rate is 92 beats per minute. What is the nurse's priority action? ## 보기 1. Hold the digoxin dose and notify the healthcare provider **✔ 정답** 2. Administer the scheduled digoxin dose as ordered 3. Increase the frequency of vital sign monitoring to every 15 minutes 4. Encourage the parents to feed the infant more frequently **정답: 1** ## 해설 Digoxin toxicity in infants presents with bradycardia (HR 92 bpm is below normal 110-160 bpm), lethargy, and vomiting. The priority is to hold digoxin and notify the provider to prevent life-threatening arrhythmias. Other options (administering digoxin, increasing monitoring, feeding) do not address the acute toxicity. ## 심화 해설 Clinical Presentation Analysis The infant is exhibiting classic signs of digoxin toxicity. The triad of lethargy, vomiting, and bradycardia in a pediatric patient receiving digoxin and a loop diuretic like furosemide should immediately raise concern for drug toxicity. The apical heart rate of 92 beats per minute is below the standard hold parameter for an infant (typically less than 90-100 bpm), making this a critical safety stop point. Pathophysiology and Risk Factors The concurrent use of furosemide, a potent loop diuretic, significantly elevates the risk for digoxin toxicity. Furosemide promotes the renal excretion of potassium, leading to hypokalemia. When serum potassium levels are low, digoxin binds more readily to the sodium-potassium ATPase pump on myocardial cells, enhancing its therapeutic and toxic effects at the same serum drug concentration. This pharmacodynamic interaction means that a standard, previously tolerated dose of digoxin can become toxic in the setting of electrolyte disturbances, a phenomenon supported by evidence that electrolyte disturbances are common predisposing factors for toxicity [1]. Additionally, infants with congenital heart disease possess unique physiological profiles that increase their vulnerability to drug-related side effects, making meticulous monitoring for toxicity a cornerstone of safe pharmacotherapy in this population [3]. Clinical Decision Making The nurse's priority action is to hold the scheduled dose and notify the healthcare provider. In the presence of clinical signs of toxicity (vomiting, lethargy) and a heart rate below the hold parameter, administering the next dose would be dangerous and could precipitate a more severe bradyarrhythmia, such as the second-degree atrioventricular block noted in pediatric cases of ongoing toxicity [1]. Pediatric antiarrhythmic medications carry a narrow therapeutic index, and emergency clinicians must be skilled in the detection and management of toxicity, which begins with immediate discontinuation of the offending agent upon recognition of adverse effects [2]. Increasing the frequency of vital sign monitoring is an appropriate intervention after the provider has been notified and the dose has been held, but it does not address the immediate threat of administering a toxic dose. Encouraging more frequent feeding is not a priority and may be contraindicated in a vomiting infant with lethargy, as it increases the risk of aspiration. The recognition and immediate withholding of the drug is the critical nursing action that prevents progression to more severe cardiotoxicity [1,2].References (research sources) - [1]Digoxin Toxicity at Standard Doses in a Child with Subclinical Elevation of Thyrotrophin: A Case Report.Case reportKhorgami M, Dalili M, Karimian B. (2025) · DOI: 10.2147/dhps.s553017 - [2]Pediatric antiarrhythmics and toxicity: A clinical review.Research articleGeanacopoulos AT, Zielonka B, Fox MT, Kerr S, Chambers KD, Przybylski R, Burns MM. (2024) · DOI: 10.1002/emp2.13090 - [3]Drug-Related Side Effects and Contributing Risk Factors in Children With Congenital Heart Disease: A Cross-Sectional Study.Research articleToni E, Ayatollahi H, Abbaszadeh R, Siahpirani AF. (2025) · DOI: 10.1002/hsr2.70835 ## 임상 시나리오 Clinical Practice Guide: Pediatric Digoxin Toxicity Assessment & Recognition - Monitor for early signs of toxicity: lethargy, vomiting, anorexia, and diarrhea are common prodromal symptoms in infants. - Assess apical heart rate for a full minute before each dose. Establish a clear hold parameter (commonly less than 90-100 bpm for infants). - Evaluate for concurrent medications that increase toxicity risk, particularly loop diuretics (furosemide) and other potassium-wasting drugs. - Review recent serum electrolyte levels, with specific attention to potassium, as hypokalemia potentiates digoxin's effect on the myocardium. Immediate Nursing Actions - **Hold the scheduled digoxin dose** if the heart rate is below the prescribed parameter or if signs of toxicity are present. - Notify the healthcare provider promptly, reporting the assessment findings including vital signs, symptoms, and recent medication administration. - Prepare for potential orders: serum digoxin level, serum electrolytes (especially potassium), renal function tests, and a 12-lead ECG to evaluate for dysrhythmias. - Initiate continuous cardiac monitoring to detect bradycardia, heart blocks, or ectopic beats. - Maintain accurate intake and output records, as renal function directly impacts digoxin clearance. Ongoing Monitoring & Prevention - Educate caregivers on signs of toxicity to report: changes in feeding pattern, unusual sleepiness, or slow heart rate. - Ensure two-nurse independent verification for all pediatric digoxin doses due to the high risk of calculation errors. - Schedule administration at consistent times and avoid giving with meals that may alter absorption. - If a dose is missed or vomited, do not administer a makeup dose; notify the provider for guidance. - Maintain strict potassium monitoring and replacement protocols when diuretics are used concurrently with digoxin. ## 핵심 개념 - **Digoxin Toxicity** — An adverse drug reaction resulting from elevated serum digoxin levels, characterized by gastrointestinal symptoms (anorexia, nausea, vomiting), neurological effects (lethargy, visual disturbances), and cardiac arrhythmias (bradycardia, heart block). - **Furosemide** — A potent loop diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle, increasing urine output and causing potassium wasting, which can precipitate digoxin toxicity through hypokalemia. - **Hypokalemia** — A serum potassium level below the normal range, which sensitizes the myocardium to digoxin by enhancing its binding to the sodium-potassium ATPase pump, thereby potentiating both therapeutic and toxic effects. - **Bradycardia (Pediatric)** — An abnormally slow heart rate for a child's age; in a 6-month-old infant, an apical pulse of less than 90-100 beats per minute is a standard nursing hold parameter for digoxin administration. - **Nursing Priority Action** — The most critical intervention based on clinical assessment, often involving withholding a medication with a narrow therapeutic index and promptly notifying the healthcare provider to prevent patient harm. ## 같은 주제 문제 - [A 4-year-old child with congenital heart disease is admitted to the pediatric unit with si…](https://mymerci.kr/pages/nclex_q.php?qn_id=541934) - [A 4-month-old infant with congenital heart disease is being evaluated for signs of heart f…](https://mymerci.kr/pages/nclex_q.php?qn_id=541935) - [A 2-year-old toddler with a history of ventricular septal defect repair is admitted to the…](https://mymerci.kr/pages/nclex_q.php?qn_id=541936) - [A 6-month-old infant with hypoplastic left heart syndrome is admitted with signs of heart …](https://mymerci.kr/pages/nclex_q.php?qn_id=541937) - [A 7-year-old child with congestive heart failure is being discharged home. 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