A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?
Bilateral cool extremities
Blood pressure 102/58 mm Hg
Serum glucose 90 mg/dL
Weak pedal pulse distal to the site
The Correct Answer is D
A. Bilateral cool extremities can be common after a cardiac catheterization due to transient vasoconstriction but is not necessarily an immediate concern if perfusion remains adequate.
B. Blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not require reporting.
C. Serum glucose of 90 mg/dL is within normal limits for a toddler and does not indicate a complication.
D. Weak pedal pulse distal to the site should be reported because it may indicate arterial occlusion or compromised circulation following the procedure. While pulses may initially be weak due to swelling, they should not be absent or significantly diminished over time.
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Related Questions
Correct Answer is C
Explanation
A. Renal calculi (kidney stones) are not directly related to fractures of the lower
extremities. They form in the kidneys and can cause pain and other symptoms when they pass into the urinary tract.
B. Osteomyelitis is a bone infection that can occur as a complication of fractures, but it typically develops over a longer period of time than the first 24 hours after the injury.
C. This is the correct answer. Compartment syndrome is a serious complication of fractures that can occur within the first 24 hours after injury. It is characterized by
increased pressure within a muscle compartment, leading to reduced blood flow, nerve compression, and tissue damage.
D. Volkmann ischemic contracture is a complication that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. It is not typically a concern within the first 24 hours after the injury
Correct Answer is C
Explanation
A. Applying warming blankets is important for maintaining the child's body temperature, but it is not the top priority in this situation.
B. Administering an IV bolus may be necessary, but it is not the priority action. The child's airway and breathing take precedence.
C. This is the correct action. In cases of submersion injury, there is a risk of respiratory distress or failure due to aspiration of water. Assisting with intubation helps ensure a patent airway and adequate oxygenation.
D. Obtaining an arterial blood gas (ABG) sample is an important assessment, but it is not the top priority. Ensuring a patent airway and providing adequate oxygenation come first.
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