A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization.

The nurse observes blood on the child’s dressing.

The correct answer is choice B. Apply direct pressure to the puncture site.

Choice A rationale:

Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.

Choice B rationale:

Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.

Choice C rationale:

Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.

Choice D rationale:

Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.

The correct answer is choice B. Continuously monitor the child’s respiratory status. This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.

Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.

Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.

Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.