A nurse is assisting with the post-operative care of a child who has undergone heart surgery to repair a septal defect.
What is a key nursing intervention during this time?

Assessing for signs of infection or bleeding at the surgical site.

Choice A rationale:

Administering herbal supplements to aid in healing is not a key nursing intervention in post-operative care for a child who has undergone heart surgery.

The use of herbal supplements should be carefully considered and discussed with the healthcare team, as they may interact with medications or affect the child's recovery.

However, it's not a primary nursing intervention.

Choice B rationale:

Monitoring the child's growth and development is an important aspect of pediatric care, but it is not the key nursing intervention during the immediate post-operative period.

The primary focus in this phase is on assessing for immediate post-surgical complications and ensuring the child's stability and recovery.

Choice C rationale:

Ensuring the child maintains complete bed rest is not a recommended intervention in the post-operative care of a child who has undergone heart surgery.

While some restrictions on physical activity may be necessary, complete bed rest is generally not advisable.

Mobilization, as appropriate, is essential to prevent complications such as deep vein thrombosis and to promote recovery.

Choice D rationale:

Assessing for signs of infection or bleeding at the surgical site is a key nursing intervention during the post-operative period.

Infection and bleeding are immediate post-operative complications that can have serious consequences.

Early detection and prompt intervention are crucial to ensure the child's safety and well-being.

Nursing assessments focus on monitoring vital signs, wound appearance, and any signs of infection or bleeding.

Choice A rationale:

Bluish discoloration of the skin, lips, or nail beds (cyanosis) is a classic symptom of cyanotic congenital heart disease (CCHD).

This occurs because of the inadequate oxygenation of the blood, which leads to oxygen-poor blood being circulated in the body.

Choice B rationale:

Poor feeding and inadequate weight gain can be associated with CCHD, especially when there is a significant reduction in cardiac output.

Infants with CCHD may have difficulty feeding due to the increased workload on their heart and may struggle to gain weight.

Choice C rationale:

Rapid breathing and shortness of breath are common symptoms in children with CCHD.

The inadequate oxygenation of the blood can lead to an increased respiratory rate and shortness of breath as the body tries to compensate for the lack of oxygen.

Choice D rationale:

Abnormal heart sounds heard during auscultation are characteristic of CCHD.

The specific type of abnormal heart sound may vary depending on the specific defect but can include murmurs, clicks, or other unusual sounds.

Choice E rationale:

Frequent respiratory infections are not typically associated with CCHD.

While children with CCHD may be more susceptible to infections due to their compromised oxygenation, it is not a direct symptom of the condition.