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."
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."
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."
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 monitor our child for any signs of infection and notify the doctor if we notice any." - "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." - "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed."
The nurse is caring for a child who has been experiencing hypercyanotic episodes. Which treatments will be effective in managing them? Select all that apply.
- Provide supplemental oxygen. - Assist the child to a knee chest position.
A child is suspected of having tricuspid atresia. Which findings are consistent with this disorder? Select all that apply.
- Weak infant sucking - Tachypnea - Bilateral crackles in lung fields
The nurse is explaining possible side effects of corticosteroids to the caregiver of a child diagnosed with rheumatic fever. The caregiver comments, "I don't understand what hirsutism means." The nurse would be correct in explaining that hirsutism is:
Abnormal hair growth
Which nursing diagnosis would best apply to a child during the acute phase of rheumatic fever?
Activity intolerance related to inability of heart to sustain extra workload
Which nursing diagnosis would best apply to a child with rheumatic fever?
Activity intolerance related to inability of heart to sustain extra workload
A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant?
Assessing for the presence of femoral pulses
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.
What information would be included in the care plan of an infant in heart failure?
Begin formulas with increased calories.
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.
The nurse is administering medications to the child with congestive heart failure. Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level?
Digoxin
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?
Digoxin
The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient?
Ineffective tissue perfusion related to inefficiency of the heart as a pump.
A 6-year-old girl is diagnosed with pulmonary 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 valve, followed by inflation of the balloon to break up adhesions
A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child?
Lower extremities
The nurse is conducting a physical examination of a 7-year-old girl prior to a cardiac catheterization. The nurse knows to pay particular attention to assessing the child's pedal pulses. How can the nurse best facilitate their assessment after the procedure?
Mark the child's pedal pulses with an indelible marker, then document.
A nurse is administering digoxin to a 3-year-old. What would be a reason to hold the dose of digoxin?
Nausea and vomiting
A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?
Notify the doctor immediately.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
Peeling hands and feet and fever
During assessment of an infant diagnosed with tetralogy of Fallot, the nurse notes bluish colored lips and irritability. Which nursing action is priority?
Place in knee-chest position.
The nurse is caring for a 6-year-old 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.
When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?
Polycythemia
Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder?
Prevent dehydration
A parent brings an infant in for poor feeding. Which assessment data would most likely indicate a coarctation of the aorta?
Pulses weaker in lower extremities compared to upper extremities.
Which nursing diagnosis will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?
Risk for ineffective cardiopulmonary tissue perfusion
A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would bemost important for the nurse to monitor?
Serum potassium level
When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?
Tachycardia
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
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?
Tetralogy of Fallot
The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?
Wheezing
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:
femoral pulse weaker than brachial pulse.
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 smaller frequent meals will tire your child less and promote weight gain."
A child will be undergoing a Holter monitor test. Which statement by the mother indicates the need for further instruction?
"My child cannot have any thing to eat or drink after midnight the day of the test."
The parents of a child having a cardiac catheterization are waiting to see the child after the procedure. What should the nurse instruct the parents to expect when seeing the child for the first time?
A bulky pressure dressing will be present over the insertion site.
An infant is prescribed digoxin. What should the nurse explain to the parents regarding the action of this medication?
Slows and strengthens the heartbeat
The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding?
Softening of the nail beds
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.