A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure.
Which of the following findings should the nurse report to the provider?
Weak pedal pulse distal to the site
Blood pressure 102/58mm Hg
Bilateral cool extremities
Serum glucose 90mg/dL
The Correct Answer is A
Choice A rationale
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
Choice B rationale
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
Choice C rationale
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
Choice D rationale
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. An increased respiratory rate is a sign of severe dehydration in infants. Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.
Correct Answer is B
Explanation
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
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