A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.

The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.

The nurse should clarify the prescription to administer sodium biphosphate/sodium phosphate because it is a laxative and is contraindicated in a child with suspected appendicitis. The use of laxatives or enemas can potentially worsen the condition by increasing the risk of perforation or rupture of the inflamed appendix.
A. Monitoring oral temperature every 4 hours is important to assess for signs of infection or worsening condition.
C. Maintaining NPO status is essential to avoid stimulating the digestive system and to prepare for possible surgery.
D. Medicating the client for pain every 4 hours as needed is appropriate to manage pain and provide comfort while the child awaits further evaluation or treatment.
Remember, it's crucial to avoid the use of laxatives, enemas, or any other interventions that can potentially aggravate the inflamed appendix in a child with suspected appendicitis.