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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.

B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.

C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.

D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.

A. An adolescent who has a BP of 132/82 mm Hg B. A 3-month-old infant who has a respiratory rate of 30/min C. An 18-month-old toddler who has a heart rate of 68/min D. A school-age child who has a rectal body temperature of 37.3° C (99.1° F)

Correct Answer is C

Explanation

A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.

B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).

C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.

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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?

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