A nurse is caring for a 5-week-old infant who has just returned from a PACU following surgery.

Exhibits

The nurse is planning care for a 5-week-old infant who is postoperative. For each intervention, click to specify if the intervention is expected or unexpected for the infant. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale for correct choices

• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.

• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.

• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.

Rationale for incorrect choices

• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.

• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.

Rationale:

A. Strabismus: Strabismus, or misalignment of the eyes, is not a known adverse effect of timolol. Timolol primarily affects intraocular pressure and systemic cardiovascular parameters rather than eye muscle alignment.

B. Bradycardia: Timolol is a nonselective beta-adrenergic blocker that can be absorbed systemically even when administered as eye drops. One potential systemic adverse effect is bradycardia, as the medication can reduce heart rate and cardiac output, particularly in clients with preexisting heart conditions.

C. Conjunctivitis: While eye irritation or mild stinging can occur with timolol, conjunctivitis is not a typical adverse effect. Instructing clients to monitor for more common ocular side effects, such as burning or discomfort, is appropriate.

D. Hyperglycemia: Timolol does not typically cause hyperglycemia. Beta-blockers can sometimes mask hypoglycemia symptoms in diabetic clients but are not associated with raising blood glucose levels directly.