An 18-month-old child returned from the cardiac cath lab 1/2 hour ago. The child wakes up and begins crying. The nurse notices that the pressure dressing is becoming saturated with blood. The nurse's first action should be to:
Remove the dressing to identify where the bleeding is coming from
Let the parent hold the child to calm him
Put direct pressure on the dressing to stop the bleeding
Draw up the ordered morphine to calm the child
The Correct Answer is C
Choice A reason: This is not a good choice. Removing the dressing to identify where the bleeding is coming from can increase the risk of infection and further bleeding. The nurse should keep the dressing in place and apply direct pressure to control the bleeding.
Choice B reason: This is not a good choice. Letting the parent hold the child to calm him can worsen the bleeding by increasing the blood pressure and heart rate. The nurse should keep the child in a supine position and reassure him while applying direct pressure to the dressing.
Choice C reason: This is the correct choice. Putting direct pressure on the dressing to stop the bleeding is the first and most effective action to take in this situation. The nurse should use a sterile gauze pad or a gloved hand to apply firm and continuous pressure to the dressing until the bleeding stops or medical assistance arrives.
Choice D reason: This is not a good choice. Drawing up the ordered morphine to calm the child is not the priority action in this situation. The nurse should first stop the bleeding and then assess the child's pain level and administer the appropriate analgesic. Morphine can also cause respiratory depression and hypotension, which can complicate the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.
Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.
Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.
Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as 5% is too high for the risk of mother-to-child transmission of HIV with ART. According to the World Health Organization (WHO), the risk of transmission can be reduced to less than 5% with effective interventions, such as ART, safe delivery practices, and appropriate infant feeding¹.
Choice B reason: This statement is incorrect, as 20% is too high for the risk of mother-to-child transmission of HIV with ART. According to the WHO, the risk of transmission can be reduced to less than 5% with effective interventions, such as ART, safe delivery practices, and appropriate infant feeding¹.
Choice C reason: This statement is incorrect, as 15% is too high for the risk of mother-to-child transmission of HIV with ART. According to the WHO, the risk of transmission can be reduced to less than 5% with effective interventions, such as ART, safe delivery practices, and appropriate infant feeding¹.
Choice D reason: This statement is correct, as 1% is the approximate risk of mother-to-child transmission of HIV with ART. According to HIV.gov, if a woman with HIV takes HIV medicine as prescribed throughout her pregnancy and childbirth and gives HIV medicine to her baby for 2-6 weeks after giving birth, the risk of transmitting HIV to the baby can be less than 1%.
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