This is a 3-year-old with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The client is here for a follow-up visit. Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.
Explanation & Rationale
The correct answers are A, D, E. Before the cardiac catheterization for a 3-year-old with a history of ventricular septal defect, the nurse's focused assessment should include the following: A. Determine when the child last ate: Knowing when the child last ate is important because the procedure may require fasting, and the nurse needs to ensure that the child has adhered to the fasting guidelines. D. Locate and mark the pedal pulses: Locating and marking the pedal pulses is essential to establish a baseline for assessing peripheral circulation, especially given the history of ventricular septal defect. E. Obtain a history of allergic reactions: Obtaining a history of allergic reactions is important to ensure that there are no allergies or sensitivities that could impact the procedure or the use of any contrast materials during the cardiac catheterization. The other options are not necessary components of the focused assessment in preparation for the cardiac catheterization: B. Measure the child's height and weight: Measuring height and weight may be done at some point but is not a priority in the immediate pre-procedural assessment. C. Perform a mini-mental exam on the child: A mini-mental exam may not be applicable or necessary in the pre-catheterization assessment of a 3-year-old. F. Document lying, sitting, and standing blood pressures: Blood pressure variations in different positions are typically not relevant for this type of procedure, and it may not be practical or necessary for a 3-year-old.