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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.
Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.
Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
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