The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity:

Question

1. Has a capillary refill of greater than three seconds.
2. Is warm, with a capillary refill of less than three seconds.
3. Has decreased sensation with a weakened dorsalis pedis pulse.
4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.

Answer 1

2
Rationale 1: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 2: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.
Rationale 3: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 4: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
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