A nurse is caring for an infant with cyanosis and a ventricular septal defect (VSD).
The nurse should expect which of the following symptoms in this patient?

Choice A rationale:

Checking the child's oxygen saturation using a pulse oximeter is an appropriate action during the assessment of a child with a congenital heart defect.

Oxygen saturation monitoring helps assess the child's oxygen levels, which is crucial in determining the adequacy of oxygen supply to the body.

Children with congenital heart defects are at risk of reduced oxygen levels, and monitoring oxygen saturation is a vital part of their care.

Choice B rationale:

Ensuring the child receives all their vaccinations is important for the child's overall health but is not directly related to the assessment of a congenital heart defect.

Vaccinations are typically administered as part of routine healthcare, but they do not address the specific concerns related to a congenital heart defect assessment.

Choice C rationale:

Assessing the child's neurological development is important but is not the primary focus of the assessment for a congenital heart defect.

While neurological assessment is important for overall child development, it does not directly relate to the cardiac assessment.

Choice D rationale:

Monitoring the child's growth based on height alone is not a comprehensive assessment for a child with a congenital heart defect.

Monitoring growth should include various parameters, such as weight, head circumference, and developmental milestones.

Relying solely on height may not provide a complete picture of the child's overall development.

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.