A nurse is caring for a 5-week-old infant who has just returned from a PACU following surgery.

Exhibits

The nurse is planning care for a 5-week-old infant who is postoperative. For each intervention, click to specify if the intervention is expected or unexpected for the infant. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale:

A. Remove the cap and place it sterile-side up on a clean surface: Placing the cap with the sterile side up can contaminate the inside of the cap and potentially the solution. The cap should be placed sterile-side down or on a clean, nonsterile surface to prevent contamination of the sterile solution.

B. Hold the bottle in the center of the sterile field when pouring the solution: Placing the bottle over the sterile field risks contaminating it if any part of the bottle or solution touches the sterile area. The bottle should be held outside the sterile field and poured carefully to maintain sterility.

C. Place sterile gauze over areas of spilled solution within the sterile field: Once a sterile field is contaminated by spilled solution, it cannot be safely salvaged by placing sterile gauze over it. Any contamination requires replacement of the affected items to maintain aseptic technique.

D. Hold the irrigation solution bottle with the label facing away from the palm of the hand: This technique prevents the solution from contacting the label, which could obscure important information or lead to accidental contamination. Proper handling preserves sterility while ensuring the label remains legible for verification.

Rationale for correct findings:

• Hemoglobin 12 g/Dl: The client’s hemoglobin increased from 9.1 g/dL to 12 g/dL following the transfusion of 2 units of packed RBCs. This demonstrates improved oxygen-carrying capacity and correction of anemia, reflecting a positive response to the intervention.

• Hematocrit 36%: The rise in hematocrit from 27% to 36% indicates improved red blood cell volume and overall blood oxygenation. This laboratory improvement confirms that the transfusion effectively restored circulating red blood cells and addressed the client’s prior anemia.

• Blood pressure 112/74 mm Hg: The client’s blood pressure increased from 90/50 mm Hg to 112/74 mm Hg, suggesting improved hemodynamic stability. This indicates better perfusion and a positive response to both transfusion and supportive care.

• Heart rate 95/min: The decrease in heart rate from 118/min to 95/min reflects reduced compensatory tachycardia associated with anemia and hypovolemia. This demonstrates improved cardiovascular status following transfusion.

• Oxygen saturation 100% via 2 L/min nasal cannula: Oxygen saturation improved from 98% on room air to 100% on supplemental oxygen, indicating enhanced oxygen delivery and tissue perfusion. This is an objective sign of recovery from anemia and improved respiratory efficiency.

Rationale for incorrect findings

• Temperature 37.5°C (95°F): The temperature remained essentially unchanged and within normal limits. While important to monitor for infection or transfusion reactions, this finding does not reflect improvement in oxygen-carrying capacity or hemodynamic status.

• Respiratory rate 18/min: The respiratory rate remained stable and within normal limits. Although stability is positive, it does not directly reflect the improvements in hemoglobin, hematocrit, blood pressure, or oxygen saturation resulting from the transfusion.