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?

Bilateral cool extremities

Blood pressure 102/58 mm Hg

Serum glucose 90 mg/dL

Weak pedal pulse distal to the site

Answer and Explanation

The Correct Answer is D

A. Bilateral cool extremities can be common after a cardiac catheterization due to transient vasoconstriction but is not necessarily an immediate concern if perfusion remains adequate.
B. Blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not require reporting.
C. Serum glucose of 90 mg/dL is within normal limits for a toddler and does not indicate a complication.
D. Weak pedal pulse distal to the site should be reported because it may indicate arterial occlusion or compromised circulation following the procedure. While pulses may initially be weak due to swelling, they should not be absent or significantly diminished over time.

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Correct Answer is D

Explanation

A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.

B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.

C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.

D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.

A. Minimize movement of the limbs. B. Place the child in a prone position. C. Clear the area of hard objects. D. Insert a tongue blade between the teeth.

Correct Answer is C

Explanation

A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.

B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.

C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.

D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.

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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?

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