A nurse is planning care for an infant following a cardiac catheterization. Which of the following interventions should the nurse include in the plan?
Assess vital signs every 4 hours.
Monitor the color of the affected extremity.
Maintain NPO status for 8 hours.
Keep the affected extremity flexed.
The Correct Answer is B
Choice A reason: Assessing vital signs every 4 hours is important, but it is not specific to the care of an infant post-cardiac catheterization. Vital signs should be monitored according to the infant's condition and hospital policy.
Choice B reason: Monitoring the color of the affected extremity is crucial after cardiac catheterization to ensure there is no compromise in blood flow, which could indicate a vascular injury or thrombosis at the catheterization site.
Choice C reason: Maintaining NPO (nothing by mouth) status for 8 hours may be necessary before the procedure, but post-catheterization care typically includes gradual reintroduction of fluids and then food as tolerated.
Choice D reason: Keeping the affected extremity flexed is not recommended post-cardiac catheterization. The limb should be kept straight to avoid bending at the catheterization site, which could lead to bleeding or clot formation.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Applying lotion to the skin under the straps is not recommended as it can interfere with the harness's grip and may lead to slippage or improper positioning.
Choice B reason: Expecting the baby to wear the harness for only 2 weeks may be incorrect as the duration of use is typically determined by the physician based on the infant's progress and may extend beyond 2 weeks.
Choice C reason: Placing the diaper under the straps is correct as it allows for easy diaper changes without removing the harness and ensures that the harness remains in the proper position.
Choice D reason: Adjusting the straps daily is not advised unless instructed by a healthcare professional. Improper adjustments can affect the effectiveness of the harness and the treatment of developmental dysplasia of the hip.
Correct Answer is B
Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
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