A nurse is planning care for an infant who has a prescription for a Pavlik harness. Which of the following actions should the nurse take?

The correct answer is D. A school-age child who is in a spica cast.

Choice A rationale

An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.

Choice B rationale

A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.

Choice C rationale

A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.

Choice D rationale

A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.

Actions to Take:

1. Anticipate a prescription for digoxin:

   • Digoxin is commonly used in pediatric heart failure cases to improve the strength of the heart’s contractions, helping to increase cardiac output and reduce symptoms of CHF. The nurse should anticipate its use to help manage the infant’s heart function.

2. Elevate the head of the bed to a 45° angle:

   • This action helps reduce the work of breathing and decreases venous return to the heart, which can alleviate pulmonary congestion and improve respiratory function. Positioning the infant in a semi-upright position is crucial to relieve symptoms of CHF, especially when there’s evidence of respiratory distress.

Parameters to Monitor:

1. Peripheral pulses:

   • Monitoring peripheral pulses is essential in assessing the effectiveness of the heart’s ability to pump blood. The weak pedal pulses and bounding upper extremity pulses noted earlier are significant findings that need to be monitored to gauge improvement in circulation as the infant’s condition is managed.

2. Respiratory status:

   • Respiratory rate, effort (including retractions and nasal flaring), and oxygen saturation levels must be closely monitored to track the infant's progress. Improvement in respiratory status, along with reduced crackles, would indicate a reduction in pulmonary congestion.