A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Condition Most Likely Experiencing

• Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
• Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
• The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
• Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.

Actions to Take

• Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
• Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
• Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
• Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.

Parameters to Monitor

• Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
• Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
• Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
• Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.

A. This is not the site where kolpik spots are located.
B. This is not the site where kolpik spots are located.
C. Koplik spots are small, white or bluish-white spots that appear on the inside of the cheeks, usually opposite the lower molars, in people who have measles. They are a sign of the infection and can be seen one to four days before the skin rash develops. They are surrounded by a red ring and look like grains of salt. Koplik spots are very helpful for diagnosing measles, especially when other diseases have similar symptoms.
D. This is not the site where kolpik spots are located.