A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization.

The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure.

Which of the following should the nurse plan to include in the discharge teaching?

Apply pressure dressing four hours after discharge.

Call the provider if the patient’s leg feels cool to touch compared to the left extremity.

Administer acetaminophen or ibuprofen oral solution if needed for pain.

Maintain a clear liquid diet for 24 hours after discharge.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Applying a pressure dressing four hours after discharge is not typically recommended following a cardiac catheterization. The site of the catheter insertion is usually covered with a simple dressing and observed for any signs of bleeding or swelling.
Choice B rationale
While it’s important to monitor for signs of impaired circulation, such as a cool extremity, this is not the primary concern following a cardiac catheterization. The procedure involves inserting a catheter into a blood vessel, not typically affecting the peripheral temperature of the extremities.
Choice C rationale
Administering acetaminophen or ibuprofen for pain as needed is a common recommendation following procedures like a balloon angioplasty. Pain can result from the catheter insertion site and these medications can help manage it.
Choice D rationale
Maintaining a clear liquid diet for 24 hours after discharge is not typically necessary following a cardiac catheterization. Once the child is alert, they are usually provided with clear liquids and later something to eat.

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Correct Answer is A

Explanation

Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.

A. Restrain the client. B. Place the client in a side-lying position. C. Place a tongue depressor in the client’s mouth. D. Assess the client’s airway patency. E. Remove objects from the client’s bed.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.

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A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization. The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure. Which of the following should the nurse plan to include in the discharge teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?

Correct Answer is A

Explanation

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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