A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?

This is because the PR interval is longer than normal, which indicates a delay in the conduction of electrical impulses from the atria to the ventricles through the AV node. A normal PR interval is 0.12 to 0.2 seconds, or 3 to 5 small squares on the EKG strip. In this case, the PR interval is 0.35 seconds, which is more than 5 small squares.

Choice A is wrong because atrial fibrillation is a type of arrhythmia where the atria beat irregularly and rapidly, producing chaotic and variable P waves and an irregular ventricular response.

There is no constant PR interval in atrial fibrillation.

Choice B is wrong because complete heart block is a type of arrhythmia where there is no conduction of electrical impulses from the atria to the ventricles, resulting in independent and dissociated atrial and ventricular rhythms.

There are no consistent P waves or PR intervals in complete heart block.

Choice D is wrong because premature atrial complexes are extra beats that originate from the atria and interrupt the normal sinus rhythm.

They produce abnormal P waves that are different from the sinus P waves, and may have a shorter or longer PR interval depending on the timing of the impulse.

However, they do not cause a constant prolongation of the PR interval.

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically.
It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating the seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond Agitation- Sedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).