A child has had a closure device inserted in interventional radiology for an atrial septal defect (ASD). Two hours later the child is pale, tachycardic, and hypotensive. Which action by the nurse takes priority?
A.
Administer a beta blocker to slow the heart rate down.
B.
Document findings then notify the health-care provider.
C.
Increase the rate of the IV fluid administration.
D.
Prepare the child to return to interventional radiology.
ANS: D
Complications from insertion of closure devices include bleeding, cardiac tamponade, or migration of the device. The provider needs to be notified stat, and the child prepared to return to the interventional radiology suite. A beta blocker is inappropriate in this setting. The nurse should notify the provider and obtain orders prior to changing IV fluid rates. Documentation needs to be thorough, but should wait until after the provider is notified.
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