Question

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?

1. Severe bradycardia
2. Asymptomatic after feeding
3. Bluish discoloration of the skin
4. Higher than normal body weight

Answer 1

The most common assessment finding in a child with a right-to-left cardiac shunt is bluish discoloration of the skin, known as cyanosis.

Step-by-step explanation:

The nurse should expect to note documentation of bluish discoloration of the skin as the most common assessment finding in a child with a diagnosis of a right-to-left cardiac shunt. This condition, also known as a 'blue baby,' occurs when there is an insufficient supply of oxygenated blood in the body, leading to cyanosis.

In this case, regardless of normal skin pigmentation, the child's skin may appear blue or purple, especially when active. This discoloration is a result of the inadequate oxygenation of the blood.

It is important for the nurse to recognize this finding and provide appropriate care and interventions to ensure the child's wellbeing.