NUR 236 PrepU Chapter 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

The parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best?

"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes."

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."

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."

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

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.

The nurse is caring for a child admitted to the hospital for a cardiac catheterization. Upon return from the cardiac catheterization, which nursing action is priority?

Assess the dressing at the insertion site.

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

Breastfeed with small, frequent feeds.

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 caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority?

Initiate intravenous access.

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.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia

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?

These wires are connected to the heart and will detect if your infant's heart gets out of rhythm.

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.

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

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

nonsterioidal anti-inflammatory drugs (NSAIDs)

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 1-day-old newborn with patent ductus arteriosus with the following vital signs: pulse 160, respirations 80, oxygen saturation 92%, retractions, and crackles noted in bilateral lungs. Which nursing actions are appropriate at this time? Select all that apply.

Administer furosemide. Initiate intravenous access. Apply oxygen via oxyhood. Begin indomethacin infusion.

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

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 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

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; fever

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Place the infant in the knee-chest position.

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

Polycythemia

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.

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.

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

Which finding(s) is a major criterion used to help the health care provider diagnose acute rheumatic fever in a child? Select all that apply.

painless nodules located on the wrists pericarditis with the presence of a new heart murmur

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

tetralogy of Fallot