The nurse caring for a 22-pound 1-year-old child who has had open heart surgery is aware that the minimum acceptable urine output for the child

A. Obtaining a throat culture and B. visualizing the epiglottis with a tongue depressor are not safe actions for the nurse to perform without appropriate medical equipment and expertise. These actions can trigger a sudden airway obstruction in a child with epiglottitis. The priority is to ensure airway patency and seek immediate medical assistance.

C. Place the child in an upright position.

Suspected epiglottitis is a medical emergency that can result in rapid airway obstruction. Placing the child in an upright position helps improve airflow by allowing the throat to open and reduces the risk of complete airway obstruction. It's important not to perform invasive procedures (such as throat culture or visualization of the epiglottis) without proper medical equipment and expertise, as these actions can lead to worsening airway obstruction.

D. Transporting the child to radiology for a throat x-ray is not appropriate in this situation, as it may delay necessary interventions to secure the airway.

A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.

B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.

C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.

D. Monitor for increased temperature.

Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.