Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.

Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.