Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.

Choice A rationale
Keeping the head of the bed at a 30-degree angle is not typically necessary following scoliosis repair with Harrington rod instrumentation. The position of the bed is usually determined by the patient’s comfort and the surgeon’s specific post-operative instructions.
Choice B rationale
Initiating the use of a PCA (Patient-Controlled Analgesia) pump for pain control is a common intervention following scoliosis repair with Harrington rod instrumentation. This allows the patient to self-administer pain medication as needed, providing effective and individualized pain control.
Choice C rationale
Repositioning the client by log rolling every 4 hours is a common practice after spinal surgery to prevent pressure ulcers and maintain alignment of the spine. However, it is not the primary intervention in this case.
Choice D rationale
Placing the client in protective isolation is not typically necessary following scoliosis repair with Harrington rod instrumentation. Isolation is usually reserved for patients who are at high risk of infection or who have an infection that could be transmitted to others.