A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider?

Question

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Chest tubes may be placed during cardiac surgery to help drain fluid and air and to ensure room for lung expansion. The chest tube and chamber should be assessed every hour for color and quantity of drainage. Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported immediately to the health care provider (Option A). This could indicate postoperative hemorrhage and requires immediate intervention. Cardiac tamponade can develop rapidly in children and can be life-threatening. This child weighs 4 kg and an output of 50 mL in 1 hour is excessive. (Option B) For infants age 1-12 months, the normal heart rate is 90-160/min. (Option C) Hypothermia is common after surgery. Warmers may be used to correct the client's temperature. (Option D) Hourly urine output should be measured in the postoperative infant. A urinary catheter is often placed during surgery, allowing for accurate measurement. Urine output should be 1-2 mL/kg/hr. Educational objective: The nurse should immediately report chest tube drainage >3 mL/kg/hr over 3 consecutive hours or >5-10 mL/kg over 1 hour, which could indicate postoperative hemorrhage. Cardiac tamponade can occur rapidly in children and can be life-threatening.

A 3-Month-Old Who Weighs 8