The nurse is checking peripheral perfusion to a child's extremity ...

[dakota nelson]

The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation,the nurse would find that the extremity
 
  1. has a capillary refill of greater thanthree seconds.
  2. has a palpable dorsalis pedis pulsebut a weak posterior tibial pulse.
  3. has decreased sensation with aweakened dorsalis pedis pulse.
  4. is warm,with a capillary refill of lessthan three seconds.

Question 2

An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode (tetspell). Which of the following nursing interventions should the nurse implement? (Select all that apply.)
 
  1. Place the child in knee-chestposition.
  2. Draw blood for a serum hemoglobin.
  3. Administer oxygen.
  4. Administer morphine andpropranolol intravenously as ordered.
  5. Administer Benadryl as ordered.

[abro1885]

Answer to Question 1

Answer:4
Rationale: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation.Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses,adequate sensation,and pinkness of skin color.If the capillary refill is over three seconds;if any of the pedal pulses are absent and/or weakened;or if the extremity is cool, cyanotic,or lacking sensation,circulation may not be adequate.

Answer to Question 2

Answer:1,3,4
Rationale: When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode,interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore,the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities),and administer oxygen,morphine,and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed.Benadryl is not appropriate for this child.