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

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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? "This disorder is caused by genetic factors." "Children who have this diagnosis may have had strep throat." "The onset and progression of this disorder is rapid." "Being up-to-date on immunizations is the best way to prevent this disorder."

"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 taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells? "He takes one nap a day and is fairly active." "He does not seem to have difficulty breathing." "He likes to stop and squat wherever he walks." "He walks very quickly and never stops moving."

"He likes to stop and squat wherever he walks." Explanation: The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance. Constant movement and quick walking are normal for a toddler. Activity level with a daily nap is typical of a toddler. Difficulty breathing would suggest a problem.

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? "Are you sure you are making nutrient-dense foods?" "It's hard to get your child to eat enough at this age to maintain their weight since they are expending so much energy with the heart condition." "Maybe your child doesn't really like the foods your making. This could lead to not gaining sufficient weight." "It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain."

"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.

When educating the family of an infant with a small, asymptomatic atrial septal defect (ASD), what information would be included in the education? "The medication indomethacin is used to try to close the hole." "The medication prostaglandin E1 is used to try to close the hole." "Most infants do not need surgical repair for this." "Surgery is usually performed in the first two months of life for this."

"Most infants do not need surgical repair for this." Explanation: Most infants do not need surgical repair for an ASD unless they are symptomatic. The hole will close spontaneously 87% of the time. The medication indomethacin is used to help close the opening of a PDA, and the medication prostaglandin E1 is used to keep a patent ductus arteriosus (PDA) open. These medications are not used for ASDs.

A nurse is taking the history of a 4-year-old child who will undergo a cardiac catheterization. Which statement by the parent may necessitate rescheduling of the procedure? "My child seems listless and slightly warm." "My child tells me about headaches because of being scared and nervous about the procedure." "My child kept scratching the chest, so I applied hydrocortisone cream to stop the itching." "My child is allergic to iodine and shellfish."

"My child seems listless and slightly warm." Explanation: Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should assess the head pain and the child's fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. The report of itching on the child's chest should be evaluated and reported to the health care provider but does not necessarily warrant cancellation of the procedure unless determined that it is a sign of a viral infection.

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? "We need to avoid a tub bath for the next 3 days." "The feeling of the heart skipping a beat is common." "Strenuous activity should be limited for the next 3 days." "We need to watch for changes in skin color or difficulty breathing."

"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? "To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years." "If she needs dental surgery, we might need additional medication." "She needs to take the drug for the full 14 days." "We can stop the penicillin when her symptoms disappear."

"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 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." "I can only place oxygen on your child if the doctor orders oxygen." "Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." "This is something we should talk with the physician about. Maybe it would help your baby."

"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 takes an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant? 100 beats per minute 150 beats per minute 60 beats per minute 80 beats per minute

100 beats per minute Explanation: Digoxin is a cardiac glycoside that works by increasing the contractility of the heart muscle. It decreases conduction and increases the force of the heart beat. The result is a slowing of the heart rate. An 8-month-old infant has a normal range of heart rate of 80 to 150 beats per minute while awake and resting, and 80 to 130 beats per minute while sleeping. The accepted practice for this age child is to withhold the digoxin if the heart rate is 90 beats per minute or less. It would be safe to administer the drug if the heart rate is 100 beats per minute. If the child has a heart rate of 150 beats per minute, further assessment should be made prior to administering the drug.

The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy? 100 to 120/70 to 80 mm Hg 80 to 100/64 to 80 mm Hg 80 to 90/40 to 64 mm Hg 94 to 112/56 to 60 mm Hg

100 to 120/70 to 80 mm Hg Explanation: The normal adolescent's blood pressure averages 100 to 120/70 to 80 mm Hg. The average infant's blood pressure is about 80/55 mm Hg. The toddler or preschool-age child's blood pressure averages 90 to 110/55 to 75 mm Hg. The normal school-age child's blood pressure averages 100 to 120/60 to 75 mm Hg.

The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply. 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse 12-year-old child whose digoxin level was 0.9 ng/ml on a blood draw this morning 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 4-month-old child with an apical heart rate of 102 beats per minute 16-year-old child with a heart rate of 54 beats per minute

16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse Explanation: The nurse should not administer digoxin to children with the following issues: apical pulse under 60 beats per minute, digoxin level above 2 ng/ml, and signs of digoxin toxicity.

A nurse is preparing to administer a prescribed dose of digoxin to an 6-month-old infant. After assessing the infant's apical pulse, the nurse decides to withhold the dose and notify the health care provider. The nurse bases this decision on which apical pulse rate? 80 beats/min 102 beats/min 94 beats/min 118 beats/min

80 beats/min Explanation: Prior to administering each dose of digoxin, the nurse would count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The nurse would withhold the dose and notify the health care provider if the apical pulse is less than 60 in an adolescent, less than 90 in an infant.

Which nursing diagnosis would best apply to a child with rheumatic fever? Disturbed sleep pattern related to hyperexcitability Risk for self-directed violence related to development of cerebral anoxia Activity intolerance related to inability of heart to sustain extra workload Ineffective breathing pattern related to cardiomegaly

Activity intolerance related to inability of heart to sustain extra workload Explanation: Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.

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? Ensure that the child's leg is kept straight. Contact the physician. Apply pressure 1 inch above the site. Change the dressing.

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? Prepare for balloon angioplasty. Assess blood pressure in all extremities. Apply appropriate oxygen device. Contact the health care provider.

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.

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 Record pedal pulses Keep the child NPO for 2 to 4 hours before the procedure Apply EMLA cream to the catheter insertion site

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? Maintain child in the supine position. Encourage larger, less frequent feedings. Begin formulas with increased calories. Administer digoxin even if the infant is vomiting.

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? Feed on schedule every 4 hours to promote rest. Breastfeed with small, frequent feeds. Assess weight gain monthly. Ensure output of a minimum 5 wet diapers daily.

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 caring for a child diagnosed with rheumatic fever. When addressing the child's pain, the nurse should perform which intervention(s)? Select all that apply. Prioritize nonpharmacologic interventions over pharmacologic interventions. Teach the child how to use a patient-controlled analgesia system. Administer intravenous morphine as prescribed. Administer salicylates after meals or with milk. Carefully handle the child's knees, ankles, elbows and wrists when moving the child.

Carefully handle the child's knees, ankles, elbows and wrists when moving the child. Administer salicylates after meals or with milk. Explanation: Pain control and relief are the highest priorities for the child with rheumatic fever. Position the child to relieve joint pain. Large joints, including the knees, ankles, wrists, and elbows, are usually involved. Carefully handle the joints when moving the child to help minimize pain. Salicylates are administered in the form of aspirin to reduce fever but primarily to relieve joint inflammation and pain. They are also used as a heart-protective. They are prescribed in high dosages. These are more commonly administered instead of opioids. Patient-controlled anesthesia is not typically used. Nonpharmacologic interventions can be used as an adjunct to pain medications.

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 B with a total cholesterol level of 175 mg/dl and LDL of 105 mg/dl. Child C with a total cholesterol level of 190 mg/dl and LDL of 125 mg/dl. Child D with a total cholesterol level of 220 mg/dl and LDL of 138 mg/dl. Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl.

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 caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? Indomethacin Alprostadil Furosemide Digoxin

Digoxin Explanation: Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force. Alprostadil is indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects. Furosemide is used for the management of edema associated with heart failure. Indomethacin is used to close a patent ductus arteriosus.

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

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.

A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent? Have the child be seen by the primary care provider. Have the child drink fluids that contain electrolytes. Have the child go to the emergency room. Give acetaminophen for the fever and pain, and have the child rest.

Have the child be seen by the primary care provider. Explanation: Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

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 A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video X-rays are directed toward the heart

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? Hypertension Hypovolemia Hyperexcitability Hypothermia

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 reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia? Decreased RBC Increased RBC Decreased WBC Increased WBC

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? Impaired gas exchange related to a right-to-left shunt Impaired skin integrity related to poor peripheral circulation Ineffective tissue perfusion related to inefficiency of the heart as a pump Ineffective airway clearance related to altered pulmonary status

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 nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin? Hypertension Ataxia Nausea and vomiting Fever and tinnitus

Nausea and vomiting Explanation: Digoxin is a cardiac glycoside and antiarrhythmic. It can cause toxicity if the dosages increase due to poor absorption, dehydration, etc. Signs of digoxin toxicity are nausea and vomiting, lethargy, and bradycardia. The apical pulse should be taken for one full minute prior to administering digoxin. The dosage should be held if the pulse rate is less than 60 beats/min in an adolescent or less than 90 beats/min in an infant. The other symptoms listed do not relate to digoxin toxicity and could occur for numerous reasons.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention? Notify the doctor immediately. Administer epinephrine. Observe vitals every two hours. Elevate the head of the bed.

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? Irritability and dry mucous membranes Peeling hands and feet; fever Low blood pressure and decreased heart rate Decreased heart rate and impalpable pulse

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? Use a calm, comforting approach. Place the child in a knee-to-chest position. Provide supplemental oxygen. Administer morphine as prescribed.

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.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority? Raise the head of the bed. Start an IV for fluids. Place the infant in the knee-chest position. Prepare the infant for surgery.

Place the infant in the knee-chest position. Explanation: Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? Leukopenia Polycythemia Anemia Increased platelet level

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.

Feb 26/ 1415 BP: 138/86 Feb 26/ 1430 BP: 132/81 March 10/ 0830 BP: 136/85 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? Reassess the blood pressure in another visit. Refer the child and family to a physical activity and nutrition education program. Plan for daily blood pressure assessments while at school. Inform the health care provider of the hypertension.

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.

The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority? Administer penicillin. Swab throat for culture. Assess skin for a rash. Evaluate C-reactive protein.

Swab throat for culture. Explanation: A child with generalized joint pain, pharyngitis, and murmur is exhibiting signs of rheumatic fever. A priority action is to obtain a throat culture to verify presence of a group A streptococcus infection and then administer penicillin. Assessing for a rash is minimally helpful as there is enough assessment data to obtain a throat culture. A high C-reactive protein is an indicator of an active infection, but it will not identify the source of the infection and the necessary pharmacologic therapy.

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 probably need surgery. Advise the child go to the emergency room. This is a normal result for a child this age. The child will need the blood pressure checked two more times.

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.

The nurse is caring for an infant prescribed oral digoxin. Which finding will cause the nurse to hold the dosage and notify the primary health care provider? The infant's respiratory rate is 58 breaths/minute. The infant's serum digoxin level is 4 ng/mL (5.12 nmol/L). The infant last ate 45 minutes ago. The infant's apical heart rate is 110 beats/minute.

The infant's serum digoxin level is 4 ng/mL (5.12 nmol/L). Explanation: The nurse would hold the dosage if the infant's serum level is 4 ng/mL (5.12 nmol/L). The therapeutic range is 0.8 to 2 ng/mL (1.02 to 2.56 nmol/L). Prior to administering each dose, the nurse should count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The dose would be withheld if the apical pulse is less than 60 in an adolescent and less than 90 in an infant. The nurse would avoid giving oral digoxin with meals as altered absorption may occur. The normal respiratory rate for an infant is 30 to 60 breaths/minute.

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 due to cardiac medications. The liver size increases in right-sided heart failure. The spleen size increases due to frequent infection. The spleen size increases due to increased destruction of red blood cells.

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 nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse? The wires are measuring the fluid level in the heart. The wires are left in the heart for 1 month after surgery in case of potential arrhythmias. These wires are connected to the heart and will detect if your infant's heart gets out of rhythm. The wires will administer ongoing electrical shocks to the heart to maintain rhythm.

These wires are connected to the heart and will detect if your infant's heart gets out of rhythm. Explanation: Following cardiac repair there is always a possibility of arrhythmias. The wires are placed and connected to an external pacemaker. This is done as a preventive measure and can be used if an arrhythmia occurs. Once it is felt the child is in no danger of an arrhythmia, the wires are removed. There is no set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization.

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason? To decrease the pain to a tolerable level To build the blood levels to a therapeutic level To establish a maintenance dose of the drug To increase the heart rate

To build the blood levels to a therapeutic level Explanation: The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention? decreased blood pressure heart murmur cool, clammy, pale extremities accentuated third heart sound

accentuated third heart sound Explanation: An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure; cool, clammy, and pale extremities; and a heart murmur are all associated with cardiovascular disorders. However, these findings do not specifically indicate sudden ventricular distention.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? fluid overload risk acute parental anxiety surgical site infection risk altered cardiopulmonary tissue perfusion risk

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 providing care to a preterm infant who has been diagnosed with patent ductus arteriosus (PDA) and developed heart failure. Which medication would the nurse expect the health care provider to prescribe to promote closure of the ductus? losartan indomethacin furosemide digoxin

indomethacin Explanation: Although digoxin, furosemide, and losartan may be used to treat congestive heart failure, they would have no effect on closing the ductus. For premature infants with heart failure due to a PDA, indomethacin, a nonsteroidal anti-inflammatory and prostaglandin inhibitor, can be utilized to facilitate closure. This is usually given in three separate IV doses.

When caring for a child with Kawasaki disease, the nurse would know that: steroid creams are used for the hand peeling. joint pain is a permanent problem. management includes administration of aspirin and IVIG. antibiotics should be administered every 8 hours by IV.

management includes administration of aspirin and IVIG. Explanation: Kawasaki disease is an acute systemic vasculitis. It is the most common form of acquired heart disease in children. The treatment is directed to reduce the inflammation in the walls of the coronary arteries and prevent thrombosis. Children are given high-dose aspirin therapy four times a day and they receive an infusion of IV immunoglobulins (IVIG) to prevent cardiac complications. Joint pain is common but not necessarily a permanent problem associated with Kawasaki disease. Antibiotics and steroid creams are not used to treat this disorder.

What would be the most important measure to implement for an infant who develops heart failure? keeping the infant supine and playing quiet games planning ways to reduce salt intake restricting milk intake daily placing the infant in a semi-Fowler position

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? pulmonary stenosis tetralogy of Fallot coarctation of aorta aortic stenosis

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.


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