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 D
Explanation
A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.
D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
Correct Answer is D
Explanation
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
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