A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:

Continuous swallowing is correct. Continuous swallowing can be an indication of postoperative bleeding after a tonsillectomy and adenoidectomy. Increased swallowing may suggest blood trickling down the throat, prompting the child to swallow frequently. It's an important sign to observe for and could indicate a risk of hemorrhage.

Choice B Reason:

Heart rate 54/min. While a low heart rate (bradycardia) might be a concern in some cases, it's not a typical sign of hemorrhage after this specific surgery.

Choice C Reason:

Blood pressure 95/56 mm Hg. While a drop-in blood pressure could be concerning for hemorrhage, this blood pressure reading alone may not necessarily indicate postoperative bleeding. Monitoring trends and other signs are important for a comprehensive assessment.

Choice D Reason:

Flushing of the face. Facial flushing is not typically associated with hemorrhage after a tonsillectomy and adenoidectomy. It might be related to other factors but is not a specific indicator of bleeding following this surgery.

Choice A Reason:

Acknowledge the family members' feelings of guilt. While it's important to validate the family's feelings and provide emotional support, assuming or acknowledging guilt without evidence could be harmful. Instead, the nurse should offer empathy and support without attributing blame.

Choice B Reason:

Discourage the parents from allowing siblings to view the body. The decision of whether siblings should view the body is personal and should be respected based on the family's beliefs and preferences. The nurse should offer guidance and support, allowing the family to make an informed decision.

Choice C Reason:

Avoid discussing details of the attempt to revive the infant. Discussing the attempt to revive the infant might help the family understand the medical interventions performed and the efforts made. However, it should be approached with sensitivity and based on the family's readiness to receive such information.

Choice D Reason:

Provide a follow-up phone call 1 week following the infant's death. Following up with the family after a week allows for ongoing support, assessment of their emotional well-being, and providing additional resources or guidance as needed during the grieving process.