A nurse is caring for a client in the emergency department (ED).

Exhibits

Which of the following interventions should the nurse implement?

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.

Choice A rationale:
Correct Answer. Placing the medication along the side of the child's tongue is a recommended technique for administering oral medication to infants. This helps prevent the infant from spitting out the medication and encourages swallowing. Placing the medication directly on the center of the tongue might trigger the gag reflex.
Choice B rationale:
Putting small bits of ice on the child's tongue prior to administering the medication is not a standard technique and is not necessary for giving liquid medication. This could potentially create discomfort for the infant and may not contribute to effective medication administration.
Choice C rationale:
Positioning the child on their back during administration of the medication is not ideal. This position might increase the risk of choking. Placing the child in an upright or slightly inclined position is generally recommended to aid in swallowing and prevent choking.
Choice D rationale:
Adding the medication to the child's formula prior to feeding is not advisable without consulting a healthcare provider. Mixing medication with formula can alter the medication's effectiveness or interactions. It's important to administer medications separately from formula to ensure accurate dosing. The correct answer is choice C. Document the infant's respiratory rate every 2 hr. The correct answer is choice D. Adopted. The correct answer is choice A. "You should place the medication along the side of your child's tongue during administration."