Chapter 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

The nurse is caring for a child with heart failure related to a congenital heart defect. One of the nursing diagnoses identified includes "Excess fluid volume." During a family care planning conference. the parents ask why this diagnosis applies to their child. What is the best response by the nurse?

"Cardiac problems cause the heart to not pump effectively, which causes swelling in the body and fluid in the lungs." Explanation: This response best explains the meaning of the nursing diagnosis and it's cause. Although there are standardized care plans as a guide, each care plan must be individualized to the client. Stating, "The heart is a pump and it isn't pumping effectively" does not explain the nursing diagnosis. Telling the parents not to worry does not help in educating them.

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

"Children who have this diagnosis may have had strep throat." Explanation: Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

The nurse is reviewing nutritional recommendations with the parents of a teen diagnosed with hyperlipidemia. Which statements indicate an understanding of the recommended diet for this condition? Select all that apply.

"I should plan to have vegetables with each evening meal served." "Adding fresh fruits to my child's lunch is a good idea." "My child loves chicken and I can still serve it but I need to remove the skin." Explanation: Hyperlipidemia refers to high levels of lipids (fats/cholesterol) in the blood. High lipid levels are a risk factor for the development of atherosclerosis, which can result in coronary artery disease, a serious cardiovascular disorder occurring in adults. Dietary management is the first step in the prevention and management of hyperlipidemia in children older than 2 years of age. The diet should consist primarily of fruits, vegetables, low-fat dairy products, whole grains, beans, lean meat, poultry, and fish. As in adults, fat should account for no more than 30% of daily caloric intake. Fat intake may vary over a period of days, as many young children are picky eaters. Limit saturated fats by choosing lean meats, removing skin from poultry before cooking, and avoiding palm, palm kernel, and coconut oils as well as hydrogenated fats.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?

"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." Explanation: Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child. Questioning the parents as to whether they are making nutritious foods or foods preferred by the child does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.

A pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can do to reduce the risk of this type of condition occurring in her baby. What information should the nurse mention to this client?

"Make sure you are fully immunized." Explanation: The cause of congenital heart disease often cannot be documented, although it is associated with familial patterns of inheritance and possibly triggers such as rubella (German measles) and varicella (chickenpox) infection during pregnancy. Women need to enter pregnancy fully immunized to help prevent infection during pregnancy. Encouraging the child to eat a low-sodium diet and exercise as he or she grows up will help prevent acquired heart disease, not congenital heart disease.

A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction?

"My child cannot have any thing to eat or drink after midnight the day of the test." Explanation: Ambulatory electrocardiographic monitoring (Holter) testing is an exam that spans approximately 24 hours. The test is done to review the activity of the heart. The child is encouraged to follow one's normal activities during the test. There is no need for the child to be NPO prior to or during the test.

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?

"The feeling of the heart skipping a beat is common." Explanation: Reports of heart "fluttering" or "skipping a beat" should be reported to the doctor as this can be a sign of a complication. The tub bath statement is appropriate because tub baths should be avoided for about 3 days. The strenuous activity statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

"We can stop the penicillin when her symptoms disappear." Explanation: For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply.

"We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." Explanation: With the Gore® Helex device, strenuous activity should be avoided for 2 weeks after the procedure, so neither soccer or bicycle riding would be allowed. Children should be monitored for the possible presence of atrial arrhythmias (lifelong) after surgical closure for the defect. Infection is a complication that must be monitored for and reported to the physician, and medications must be given as prescribed.

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse?

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." Explanation: For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential. Although oxygen must be ordered by the physician and it isn't the best treatment, the nurse stating, "While it seems that oxygen would help, it actually makes the condition worse. Treating the cause of the disease will help" best answers the question while also showing empathy.

The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

"Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder." Explanation: To compensate for low blood oxygen levels, the kidneys produce the hormone erythropoietin to stimulate the bone marrow to produce more red blood cells (RBCs). This increase in RBCs is called polycythemia. Polycythemia can lead to an increase in blood volume and possibly blood viscosity, further taxing the workload of the heart. The correct response is the clearest and easiest description for the parents to understand. Telling the parents the doctor was discussing polycythemia with them doesn't answer their question.

The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate?

Apply pressure 1 inch above the site. Explanation: If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.

The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first?

Assess blood pressure in all extremities. Explanation: An infant with decreased pulse strength in the lower extremities may have coarctation of the aorta. Assessing blood pressures in all extremities is most helpful in assisting the nurse with gathering assessment data prior to contacting the health care provider. The nurse does not have enough information to apply oxygen at this time or prepare the newborn for balloon angioplasty.

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?

Assessing for the presence of femoral pulses Explanation: Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?

Avoid drawing a blood specimen from the right femoral vein before the procedure Explanation: Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

What information would be included in the care plan of an infant in heart failure?

Begin formulas with increased calories. Explanation: Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease?

Breastfeed with small, frequent feeds. Explanation: Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily. Feeding every 4 hours will not promote the intake and growth required for an infant with CHD.

The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl. Explanation: Total cholesterol levels below 170 mg/dl and LDL levels less than 100 mg/dl are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dl and LDL levels greater than or equal to 130 mg/dl are considered elevated and place this child at greatest risk.

The nurse is assessing the heart rate of a 6-month-old infant and determines it to be 82 beats/min. What action should the nurse take first?

Conduct a focused cardiovascular assessment. Explanation: The normal infant heart rate averages 90 to 160 beats/min. This infant's heart rate is low. The nurse should first conduct a focused cardiovascular assessment. After that is completed, the findings can be reported to the health care provider. Obtaining a health history can be beneficial, but with a low heart rate, the nurse would want to know first if there are any other clinical signs indicating a problem or a reason for the heart rate. The heart rate should be reassessed, but not necessarily in a 5-minute window. The heart rate should be assessed via apical pulse for a full 60 seconds.

The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level?

Digoxin Explanation: The use of large doses of digoxin at the beginning of therapy to build up the blood levels of the drug to a therapeutic level is known as digitalization. During the 24 hours digitalization is occurring, the child should be on a cardiac monitor and the nurse should monitor the PR interval and a decreased ventricular rate. The other listed medications are not administered in this manner. Albuterol is inhaled for asthma treatment and used primarily for exacerbations. Ferrous sulfate is give for iron-deficiency anemia, and spironolactone is a diuretic.

A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting?

Feeding problems Explanation: The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works?

High-frequency sound waves are directed toward the heart Explanation: Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. An echocardiogram involves high-frequency sound waves, directed toward the heart, being used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers; thickness of walls; relationship of major vessels to chambers; and the thickness, motion, and pressure gradients of valves. You can remind parents that echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

On assessment immediately following cardiac surgery, which condition would the nurse expect to find in an infant?

Hypothermia Explanation: Cardiac surgery is often performed under hypothermia to decrease the child's oxygen needs during surgery. The postoperative care nurse should assess the infant's vital signs continuously via monitoring. The temperature should be assessed at least once per hour until an optimal temperature is achieved. The infant would have received IV fluids during surgery so hypovolemia should not be the primary concern. The infant will be sleepy from anesthesia, not hyperexcited. Hypertension, if any, has been monitored throughout the surgery and controlled.

A nurse is caring for a 10-week-old male infant in the emergency department. Assessment reveals: congestive cough, crackles in the lower lung fields, cyanosis of extremities, capillary refill >2 seconds, diaphoretic, respiratory rate of 80 breaths/min with subcostal and suprasternal retractions, oxygen saturations of 90% on room air, heart rate 190 beats/min, murmur auscultated, blood pressure left arm 86/45 mm Hg, and temperature 96.8°F (36°C). Weight 15.2 lb. (6900 g). Parents state weight is up from 13.4 lb. (6100 g) the other day. Laboratory values: brain-type natriuretic peptide is elevated; sodium (serum), 128 mEq/l (128 mmol/l); potassium (serum), 4.3 mEq/l (4.3 mmol/l); blood urea nitrogen (BUN), 3 mg/dl (1.09 mmol/l). The nurse suspects the infant's condition may be related to a congenital heart condition.

Increased Pulmonary Blood Flow Heart Defect - respiratory rate of 80 breaths/min, heart rate of 190 beats/min, murmur, diaphoresis crackles in the lung fields, blood pressure of 86/45 mm Hg Mixed Flow Heart Defect - crackles in the lung fields, blood pressure of 86/45 mm Hg Explanation: Normal heart rate for a 10-week-old infant is 123 to 164 beats/min. This infant's heart rate is higher than normal, thus the infant has tachycardia. Normal respiratory rate for a 10-week-old infant is 34 to 57 breaths/min. This infant's respiratory rate is higher than normal, thus the infant has tachypnea. Normal blood pressure for a 1-week-old infant is 87-105/53-66 mm Hg. This infant's blood pressure is within normal limits for the age group. Signs and symptoms of increased pulmonary blood flow congenital heart defects include tachypnea, tachycardia, murmur, diaphoresis, and heart failure (fluid excess). Signs and symptoms of mixed flow congenital heart defects include cyanosis, poor weight gain, pulmonary congestion, and heart failure (fluid excess). Signs and symptoms of increased pulmonary blood flow congenital heart defects include tachypnea, tachycardia, murmur, diaphoresis, and heart failure (fluid excess). Signs and symptoms of decreased pulmonary blood flow include cyanosis, poor weight gain, hypercyanotic episodes, and polycythemia. Signs and symptoms of increased pulmonary blood flow congenital heart defects (not mixed flow heart defects) include tachypnea, tachycardia, murmur, diaphoresis, and heart failure (fluid excess).

A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia?

Increased RBC Explanation: Polycythemia can occur in clients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply?

Ineffective tissue perfusion related to inefficiency of the heart as a pump Explanation: A ventricular septal defect permits blood to flow across an opening between the right and left ventricles. It results in increased pulmonary blood flow, but it does not cause cyanosis. The blood in the left ventricle, which flows back into the right ventricle, is already oxygenated. Anytime there is an opening between the heart's ventricles, the heart is not as effective as a pump because the pressure gradients are changed. A ventricular septal defect will not cause respiratory problems or problems with peripheral circulation.

A 6-year-old girl is diagnosed with aortic stenosis. The mother asks the nurse what the likely treatment for this condition will involve. What should the nurse tell the mother?

Insertion of a catheter with an uninflated balloon tip into the affected area followed by inflation of the balloon to open the narrowing Explanation: Balloon angioplasty by way of cardiac catheterization is the initial procedure for aortic stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed area. As the balloon is inflated, it breaks any adhesions and opens the area. The other answers refer to interventions related to patent ductus arteriosus, not aortic stenosis.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

Notify the doctor immediately. Explanation: The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

Peeling hands and feet; fever Explanation: Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position. Explanation: The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed. A calm, comforting approach should be used but is not the priority action.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?

Polycythemia Explanation: Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated. Leukopenia, increased platelets, and anemia are not associated with tetralogy of Fallot.

The school nurse has assessed a 12-year-old child's blood pressure (above). Based on these assessment findings, what will the nurse do next? BP February 26 14:15 ; 138/86 BP February 26 14:30 ; 132/81 BP March 10 8:30; 136/85

Reassess the blood pressure in another visit. Explanation: A diagnosis of hypertension requires three separate elevated readings in three separate visits. Because two of these readings were taken in the same visit, the child should be asked to return for a third assessment of blood pressure in another visit. If hypertension is diagnosed, then informing the health care provider and referral to a family-based intervention program may be appropriate but not at this stage. Daily blood pressure assessments are not necessary.

At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?

Taking pedal pulses for the first 4 hours Explanation: Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

A nurse is providing education to a family about cardiac catheterization. What information would be included in the education?

The catheter will be placed in the femoral artery. Explanation: A cardiac catheterization can be performed via the right side of the heart or the left side. If the catheter is going through the right side it would be inserted into the femoral vein and threaded to the right atrium. If it is going to the left side the catheter would be threaded through the femoral artery to the aorta. The child will need to lie still for 4 to 6 hours with the leg outstretched after the procedure to prevent bleeding. The brachial artery is not used. The procedure is usually postponed if the child has a fever.

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

The child will need the blood pressure checked two more times. Explanation: The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure. Explanation: The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

A mother asks the nurse if the reason the infant has a congenital heart defect is because of something she did while pregnant. What is the best response by the nurse?

There are several reasons an infant can have a heart defect; let's talk about those causes. Explanation: Parents who have a newborn who has a defect are always concerned they did something wrong to cause the defect. They carry a large amount of guilt. The nurse should focus on the therapeutic communication in this situation, while still obtaining more information. A nurse should never blame the parent because it is not only nontherapeutic, but there are many reasons why congenital heart defects occur. The reason for the infant's heart defect may not be known. Using therapeutic communication will reduce the parent's anxiety and guilt. Congenital heart defects can be caused by genetic defects such as chromosomal anomalies but this is not always the case.

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age. Explanation: A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

This test will check how blood is flowing through the heart. Explanation: An echocardiogram (echo) is a noninvasive ultrasound used to assess the heart wall thickness, the size of the heart chambers, the motion of the valves and septa, and the relationship of the great vessels to other cardiac structures. The test evaluates how blood is flowing through the heart and how effective the heart is in pumping. An echo does not check the electrical impulses. This would be done with an electrocardiogram.

Parents are told that their infant has a heart defect with a left-to-right shunt. What is the best way for the nurse to explain this type of shunting to the parents?

This type of shunting causes an increase of blood to the lungs. Explanation: This type of shunting causes an increase of blood to the lungs. A right-to-left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

altered cardiopulmonary tissue perfusion risk Explanation: Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and parental anxiety will be performed after ensuring cardiopulmonary tissue perfusion is adequate.

A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note?

bounding pulse Explanation: A bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.

The nurse is assessing a child with suspected rheumatic fever. Which assessment finding(s) is consistent with the disease process? Select all that apply.

carditis involuntary limb movement macular rash on trunk tender, swollen joints Signs and symptoms of rheumatic fever include carditis; involuntary limb movement; macular rash on the trunk; tender, swollen joints; and subcutaneous nodules.

The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?

heart failure Explanation: Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, and irritability are signs of Kawasaki disease.

A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers?

nonsterioidal anti-inflammatory drugs (NSAIDs) Explanation: Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids. Insulin would be given for diabetes and phenytoin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

When developing a teaching plan for the parents of a child diagnosed with tricuspid atresia, the nurse would integrate knowledge of what factor as the major mechanism involved?

obstruction of blood flow to the lungs Explanation: Tricuspid atresia is a congenital heart defect in which the valve between the right atrium and right ventricle fails to develop, resulting in no opening to allow blood to flow from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs. It is classified as a disorder of decreased pulmonary blood flow due to obstruction of blood flow to the lungs. Defects with connections involving the left and right sides, such as atrial or ventricular septal defects, will shunt blood from the higher-pressure left side to the lower-pressure right side and subsequently more blood will go to the lungs. A narrowed major vessel leads to an obstructive defect, interfering with the ability of the blood to flow freely through the vessel. Mixed defects such as transposition of the great vessels involve the mixing of well-oxygenated with poorly oxygenated blood, leading to a systemic blood flow that contains a lower oxygen content.

What would be the most important measure to implement for an infant who develops heart failure?

placing the infant in a semi-Fowler position Explanation: Placing an infant with heart failure in a semi-Fowler position reduces the pressure of the abdominal contents against the chest and allows for better lung expansion. Keeping the infant supine would cause more pressure on the heart and lungs and increase the work of the heart and lungs. Infants with heart disease need calories to grow. They are given formula or breast milk which is fortified with extra nutrients. Thus the infant can have an intake of the same amount of fluid but receive extra nutrients.

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?

tetralogy of Fallot Explanation: Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.