A nurse on a cardiac care unit is caring for a preschooler.

Hospital Day 1, 17:38:

Medication Administration Record.

20:15:

Received 4-year-old child with an exacerbation of heart failure.

Family reports history of congenital mitral stenosis.

Breath sounds with wheezing noted in bilateral lower lobes.

Nonproductive cough noted.

Dyspnea with respiratory rate 30/min.

Oxygen at 2 L/min applied per nasal cannula.

Telemetry applied:

Sinus rhythm at rate 116/min.

Abdomen soft, nontender.

Bowel sounds positive in all 4 quadrants.

Lower extremities with 2+ edema noted.

Pedal pulses palpable bilaterally.

Peripheral saline lock intact to right forearm with no signs and symptoms of infection.

Weight 26 kg (44 lb).

Increase in dyspnea noted with orthopnea.

Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout.

Lower extremity edema 3+ to bilateral lower extremities.

Extremities cool with decreased skin pigmentation noted.

Peripheral pulses weak bilaterally.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of furosemide.

The client is at risk for developing:

Choice A rationale
Disseminated intravascular coagulation (DIC) is caused by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the coagulation cascade, leading to the formation of small blood clots throughout the bloodstream. This process consumes clotting factors and platelets, increasing the risk of severe bleeding.
Choice B rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is typically a secondary condition resulting from other underlying issues such as sepsis, trauma, or malignancy. Vitamin K deficiency can lead to bleeding disorders, but it is not the cause of DIC13.
Choice C rationale

DIC is characterized by a decreased platelet count, not an elevated one. The consumption of platelets and clotting factors in the formation of microthrombi leads to thrombocytopenia and an increased risk of bleeding.
Choice D rationale
DIC is not controllable with lifelong heparin usage. While heparin may be used in certain cases to manage DIC, it is not a lifelong treatment. The management of DIC focuses on treating the underlying cause and supporting the patient through the acute phase of the disorder.

Choice A rationale
The skin assessment reveals bruising and petechiae, which are signs of thrombocytopenia, a condition where the blood has a lower than normal number of platelets. This is significant in a child with leukemia as it may indicate a relapse or bone marrow suppression. The presence of petechiae and unexplained bruising should be reported to the provider as they can be indicative of bleeding disorders or a decrease in platelet count.
Choice B rationale
Oxygen saturation of 92% on room air is below the normal range (95-100%) for a child. This indicates hypoxemia, which can be a sign of respiratory distress or other underlying conditions. Given the child’s history of an upper respiratory infection and leukemia, this finding is critical and should be reported to the provider to ensure appropriate interventions are taken to improve oxygenation.
Choice C rationale
The WBC count is crucial in a child with leukemia. An abnormal WBC count can indicate an infection, relapse, or bone marrow suppression. Monitoring the WBC count helps in assessing the child’s immune status and the effectiveness of the leukemia treatment. Any significant changes in the WBC count should be reported to the provider for further evaluation and management.
Choice D rationale
Subcostal retractions are a sign of increased work of breathing and respiratory distress. This finding, along with the child’s statement of feeling like they can’t breathe, indicates that the child is struggling to maintain adequate ventilation. Reporting this to the provider is essential for timely intervention to prevent further respiratory compromise.
Choice E rationale
An ongoing upper respiratory infection for the last 2 months that has not resolved is concerning, especially in a child with a history of leukemia. This could indicate an underlying immunodeficiency or a more serious infection that requires further investigation and treatment. Reporting this to the provider is necessary to address the persistent infection and prevent complications.
Choice G rationale
The respiratory rate is an important vital sign that can indicate respiratory distress or other underlying conditions. An abnormal respiratory rate, whether too high or too low, can be a sign of respiratory or metabolic issues. Monitoring and reporting the respiratory rate to the provider helps in assessing the child’s respiratory status and determining the need for further intervention.