A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?
Extremities warm to touch.
Capillary refill 2 seconds.
Blood pressure 112/66 mm Hg.
Diminished pulses.
The Correct Answer is D
Choice A rationale:
Extremities warm to the touch. This manifestation is not indicative of decreased cardiac output. Warm extremities suggest adequate peripheral perfusion and circulation. In a child with decreased cardiac output, the body might attempt to shunt blood away from the extremities to prioritize vital organs, leading to cooler extremities.
Choice B rationale:
Capillary refill 2 seconds. A capillary refill time of 2 seconds is within the normal range for a preschool-aged child. This quick capillary refill suggests adequate circulation and is not a sign of decreased cardiac output. Prolonged capillary refill time might be indicative of poor peripheral perfusion.
Choice C rationale:
Blood pressure 112/66 mm Hg. While a blood pressure of 112/66 mm Hg might be within the normal range for a preschooler, it is not the most reliable indicator of decreased cardiac output. Blood pressure can be influenced by various factors, and a seemingly normal blood pressure does not rule out decreased cardiac output if other manifestations are present.
Choice D rationale:
Diminished pulses. This is the correct choice. Diminished or weak pulses are indicative of decreased cardiac output. Inadequate blood volume being pumped by the heart can lead to reduced peripheral perfusion, resulting in diminished pulses. This sign is important in assessing the child's cardiovascular status postoperatively, especially after a corrective procedure for tetralogy of Fallot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"I should start by feeding my baby 3 tablespoons of solid food." At 6 months of age, infants are typically just beginning to transition to solid foods. Starting with 3 tablespoons of solid food might be overwhelming and inappropriate for the infant's digestive system. Introducing small amounts and gradually increasing the volume allows the infant to adapt to the new textures and flavors.
Choice B rationale:
"I should limit my baby to 8 ounces of juice per day." Juice consumption should be limited for infants. Juice offers little nutritional value and can contribute to excessive calorie intake, leading to potential weight gain and tooth decay. At 6 months, the primary source of nutrition should still be breast milk or formula, and the introduction of solid foods is meant to complement, not replace these sources.
Choice C rationale:
"I should introduce a new solid food to my baby every five to seven days." This statement indicates an understanding of the recommended approach for introducing solid foods to an infant. Introducing a new food every five to seven days allows the parent to monitor for any potential allergic reactions or sensitivities. This gradual approach helps identify specific foods that the infant may not tolerate well.
Choice D rationale:
"I should sweeten my baby's food with a teaspoon of honey." This statement is incorrect and potentially dangerous. Honey should not be given to infants under 12 months of age due to the risk of infant botulism, a serious and potentially fatal illness. Honey can contain spores of Clostridium botulinum bacteria, which can multiply and produce toxins in an infant's immature digestive system. It's important to avoid honey until the child is older to ensure their safety.
Correct Answer is D
Explanation
Answer: d. Apply suction in 3 to 4-second increments.
Rationale:
- a. Instill 2 mL of 0.9% sodium chloride prior to suctioning:While saline instillations may be used in some cases,it is not universally recommended for infants with tracheostomies and depends on the specific situation and healthcare provider's protocol.The priority in this case is to quickly clear the partial mucus occlusion to prevent respiratory distress.
- b. Select a catheter that fits snugly into the tracheostomy tube:This isincorrect.Selecting a catheter that fits tightly can damage the delicate tracheal mucosa and increase the risk of bleeding.A smaller-diameter catheter that allows for gentle passage is preferred.
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Tracheostomy tube and different catheter sizes
- c. Use a clean technique when performing suctioning:This is absolutely essential for all suctioning procedures to minimize the risk of infection.However,it is not the specific action that addresses the immediate concern of clearing the partial mucus occlusion.
- d. Apply suction in 3 to 4-second increments:This is thecorrectapproach for suctioning an infant with a tracheostomy.Applying short,intermittent suction bursts minimizes the risk of hypoxia and tissue trauma while effectively removing secretions.
Therefore, the most important action for the nurse to take is to apply suction in short, 3-4 second bursts to effectively clear the mucus occlusion while minimizing risks to the infant.
Additional Points:
- The nurse should use sterile suction equipment and sterile technique throughout the procedure.
- The suction pressure should be set at the lowest effective level,typically 80-120 mmHg.
- The nurse should monitor the infant for signs of respiratory distress,such as increased work of breathing,retractions,and oxygen desaturation,before,during,and after suctioning.
- If the mucus occlusion is not cleared after several attempts,the nurse should seek assistance from ahealthcareprovider.
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