Seventy-two hours after cardiac surgery, a young child has a ...

[formula1]

Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7 C (101 F). The nurse should:
 
  a. Keep the child warm with blankets.
  b. Apply a hypothermia blanket.
  c. Record the temperature on nurses' notes.
  d. Report findings to physician.

Question 2

An important nursing consideration when suctioning a young child who has had heart surgery is to:
 
  a. Perform suctioning at least every hour.
  b. Suction for no longer than 30 seconds at a time.
  c. Administer supplemental oxygen before and after suctioning.
  d. Expect symptoms of respiratory distress when suctioning.

[blakcmamba]

Answer to Question 1

ANS: D
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an elevated temperature continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation.

Answer to Question 2

ANS: C
If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are to be avoided by using the appropriate technique.