A nurse is assessing a child with a congenital heart disease. Which symptom requires immediate intervention?

A) The answer is A. Monitoring urine output closely is essential postoperatively to assess kidney perfusion and fluid balance, as infants are at risk of fluid shifts after cardiac surgery.

B) Incorrect. While administering prescribed analgesics is important for postoperative pain management, it is not the priority intervention among the options provided.

C) Incorrect. Encouraging deep breathing and coughing exercises is important to prevent respiratory complications, but it is not the priority intervention immediately after cardiac surgery.

D) Incorrect. Elevating the head of the bed can help with respiratory effort, but it is not the priority intervention. Monitoring urine output and fluid balance is more critical in the early postoperative period.

A) Incorrect. Taking an over-the-counter pain reliever may not address the underlying cause of the symptoms and is not the appropriate action in this situation.

B) Incorrect. Deep breathing exercises may not alleviate the symptoms of shortness of breath and chest pain. The client should seek medical attention for proper evaluation and management.

C) Incorrect. While resting quietly is generally advisable, it may not be sufficient to address the client's symptoms. Seeking medical attention is essential to identify and manage the cause of the symptoms.

D) The answer is D. Shortness of breath and chest pain can be signs of a cardiac event or worsening of the congenital heart disease. The client should seek medical attention immediately to receive appropriate evaluation and treatment.