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 A
Explanation
A. This is the correct intervention. Encouraging the toddler to use an incentive spirometer helps promote lung expansion and prevent atelectasis (collapsed lung tissue), which is
important for postoperative respiratory function.
B. Placing a cooling blanket on the toddler is not a standard intervention following routine surgery. It's important to monitor the toddler's temperature and use appropriate measures if they experience hyperthermia.
C. Administering IV dantrolene sodium is used for the treatment of malignant hyperthermia, a rare but life-threatening reaction to certain medications used during anesthesia. It is not a routine postoperative intervention.
D. Aspirin is generally not recommended for pain relief in children due to the risk of Reye's syndrome. Other pain management options, such as acetaminophen or ibuprofen, are typically used for postoperative pain in children.
Correct Answer is A
Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
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