A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery.

The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)

The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.

Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.

Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.

Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.

Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.

Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.

Normal ranges for pulse oximetry are 95% to 100%, for heart rate, are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.

This is because a patent ductus arteriosus is a congenital heart defect that involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. This causes a continuous machinery-like murmur that can be heard on auscultation.

Choice A is wrong because pulmonary stenosis is a narrowing of the pulmonary valve or artery that obstructs blood flow to the lungs. It causes a systolic ejection murmur that is best heard at the upper left sternal border.

Choice C is wrong because the ventricular septal defect is a hole in the wall between the ventricles that allows blood to flow from the left to the right side of the heart. It causes a loud, harsh holosystolic murmur that is best heard at the left lower sternal border.

Choice D is wrong because coarctation of the aorta is a narrowing of the aorta that reduces blood flow to the lower body. It causes a systolic murmur that radiates to the back and weak or absent femoral pulses.