A 5-year-old child returns from the pediatric intensive care unit ...

[jwb375]

A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child's heart rate is 20 beats/min less than it was preoperatively
 
  a. Follow the orders and check in 2 hours.
  b. Ask the parents if this is the child's usual heart rate.
  c. Recheck the pulse and blood pressure in 15 minutes.
  d. Notify the surgeon that the child is probably going into shock.

Question 2

A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?
 
  a. Holding your child is unsafe.
  b. Holding may help your child relax.
  c. Hospital policy prohibits this interaction.
  d. Holding your child is unnecessary given the child's age.

[uniquea123]

Answer to Question 1

ANS: C
In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child's condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child's heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.

Answer to Question 2

ANS: B
The mother's preference for assisting, observing, or waiting outside the room should be assessed, as well as the child's preference for parental presence. The child's choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care.

[jwb375]

TYSM

[xiazhe]

Excellent