The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply.

Reference Range:

White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]

Rationale for Correct Choices:

• Myocardial infarct (MI): The client presents with chest pain described as pressure and tightness, which worsens over time. The ECG shows ST depression, a common sign of ischemia. This combined with the risk factors and vital signs support myocardial infarction.
• Prepare client for possible percutaneous coronary intervention: If a myocardial infarction is suspected, preparing the client for PCI is critical. PCI is used to treat blockages in the coronary arteries, which is essential for restoring blood flow and minimizing myocardial damage.
• Educate on nitroglycerin administration: Nitroglycerin helps alleviate chest pain by relaxing coronary arteries, reducing heart workload, and improving blood flow. It is used in MI management to relieve symptoms and reduce ischemia.
• Electrocardiogram (ECG): Continuous ECG monitoring is essential to assess the progression of any arrhythmias or ischemic changes, which are common during an MI. It allows real-time identification of worsening conditions.
• Chest pain: Monitoring chest pain closely helps evaluate the effectiveness of treatment and determine whether ischemia persists or resolves. Pain relief indicates that interventions are successful.

Rationale for Incorrect Choices:

• Atrial fibrillation: While atrial fibrillation can cause chest discomfort, the patient’s clinical presentation, including ECG findings and risk factors, is more consistent with an MI. Atrial fibrillation usually presents with irregular heartbeats rather than persistent chest pressure.
• Congestive heart failure: The current presentation, including chest pain, ECG changes, and pain unrelieved by rest, points to a myocardial infarction rather than congestive heart failure. There are no signs of fluid overload or symptoms associated with heart failure in this scenario.
• New onset angina: While the client may experience angina, the unrelieved chest pain lasting for over 30 minutes and the severity of the symptoms suggest a myocardial infarction rather than just new onset angina, which typically resolves with rest.
• Begin chest compressions: Chest compressions are necessary only in cases of cardiac arrest. While this client is experiencing chest pain and signs of an MI, there is no indication of cardiac arrest, so chest compressions are not appropriate at this point.
• Consult physical therapy: Physical therapy is not immediately needed for the acute management of myocardial infarction. The priority is stabilizing the patient's cardiac status and addressing the ischemia, not physical rehabilitation.
• Conduct a nutritional history: While a nutritional history is important for long-term heart disease management, it is not an immediate concern during an acute MI episode. The focus should be on stabilizing the patient and addressing the immediate cardiovascular issues.

• Lung sounds: Lung sounds are not directly relevant to this patient's current condition. While they may be important for detecting complications like pulmonary edema, they are not a priority when assessing for an acute MI.
• Pedal pulses: Pedal pulses can be useful in assessing peripheral circulation but are not a priority in the management of MI unless signs of shock or poor circulation are noted.
• Intake and output: While monitoring intake and output is important for fluid balance, it is not the immediate focus for managing this patient’s acute MI. The focus should be on cardiac parameters and symptom relief, such as monitoring chest pain and ECG changes.

Rationale for Correct Responses:

• Before breakfast: Monitoring blood glucose before breakfast (fasting blood glucose) is essential for evaluating how well the body is managing glucose levels overnight. It helps assess baseline blood sugar control before any food intake and provides insights into insulin sensitivity or resistance.
• Two hours after all meals: Checking blood glucose two hours post-meal helps determine how well the body is processing food, which is crucial for managing blood sugar spikes after eating.

Rationale for Incorrect Responses:

• Before bedtime: Bedtime monitoring isn't routinely necessary unless instructed by the healthcare provider for clients who are at risk of nocturnal hypoglycemia. The focus generally should be on pre-meal and post-meal blood sugar levels for optimal control.
• Only when symptomatic: Waiting for symptoms is not sufficient for diabetes management. Regular monitoring is essential to detect asymptomatic hyperglycemia or hypoglycemia before it causes complications.