Pediatrics Cardiovascular

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1.Weighing the diapers 2.Inserting a urinary catheter 3.Comparing intake with output 4.Measuring the amount of water added to formula

1. Weighing the diapers

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1.Pallor 2.Cough 3.Tachycardia 4.Slow and shallow breathing

3. Tachycardia

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1.Pallor 2.Hyperactivity 3.Activity intolerance 4.Gastrointestinal disturbances

3. activity intolerance

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure? 1.Paleness of the skin 2.Strong sucking reflex 3.Diaphoresis during feeding 4.Slow and shallow breathing

3.Diaphoresis during feeding

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1.Aortic stenosis 2.Atrial septal defect 3.Patent ductus arteriosus 4.Ventricular septal defect

3. Patent ductus arteriosus

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? 1.Withhold the medication. 2.Administer the medication. 3.Check the blood pressure and then administer the medication. 4.Check the respiratory rate and then administer the medication.

1. Withhold the medication. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1.Elevated C-reactive protein 2.Elevated antistreptolysin O titer 3.Presence of Reed-Sternberg cells 4.Presence of group A beta-hemolytic strep 5.Decreased erythrocyte sedimentation rate

1.Elevated C-reactive protein 2.Elevated antistreptolysin O titer 4.Presence of group A beta-hemolytic strep

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1.Elevated antistreptolysin O titer 2.Decreased erythrocyte sedimentation rate 3.Negative result on antinuclear antibody assay 4.Negative result on C-reactive protein determination

1.Elevated antistreptolysin O titer

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1."A balance of rest and exercise is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. "I can apply lotion or powder to the incision if it is itchy." Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition? 1.Bleeding 2.Heart failure 3.Failure to thrive 4.Decreased tolerance to stimulation

2. Heart failure

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1.Prone position 2.Knee-chest position 3.High-Fowler's position 4.Reverse Trendelenburg's position

2. Knee-chest position

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1.Prevents blue (tet) spells 2.Maintains adequate cardiac output 3.Maintains an adequate hormonal level 4.Maintains the position of the great arteries

2. Maintains adequate cardiac output

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1.Anxiety 2.A temper tantrum 3.A hypercyanotic episode 4.The need for immediate primary health care provider notification

3. A hypercyanotic episode Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate HCP notification is not required unless other appropriate nursing interventions are unsuccessful.

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the primary health care provider.

3. Administer the medication.

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher than normal body weight

3. Bluish discoloration of the skin The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities.

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1.Cracked lips 2.Normal appearance 3.Conjunctival hyperemia 4.Desquamation of the skin

3. Conjunctival hyperemia Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1."Has the child complained of back pain?" 2."Has the child complained of headaches?" 3."Has the child had any nausea or vomiting?" 4."Did the child have a sore throat or fever within the last 2 months?"

4. "Did the child have a sore throat or fever within the last 2 months?"

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1."I will not mix the medication with food." 2."I will take my child's pulse before administering the medication." 3."If more than 1 dose is missed, I will call the primary health care provider." 4."If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose." Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose.

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the primary health care provider? 1.Bradypnea 2.Diaphoresis 3.Decreased blood pressure 4.A weight gain of 1 lb (0.5 kg) in 1 day

4. A weight gain of 1 lb (0.5 kg) in 1 day

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1.Immunoglobulin 2.Red blood cell count 3.White blood cell count 4.Anti-streptolysin O titer

4. Anti-streptolysin O titer

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia? 1.Tachypnea 2.Tachycardia 3.Sucking on the fingers 4.Clubbing of the fingers

4. Clubbing of the fingers

The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate? 1. Administer acetaminophen for temperature elevation. 2. Administer the aspirin if the child's temperature is elevated. 3. Administer the aspirin if the child experiences any joint pain. 4. Consult with the primary health care provider to verify the prescription.

4. Consult with the primary health care provider to verify the prescription.

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1.Absence of C-reactive protein 2.Presence of Reed-Sternberg cells 3.Decreased antistreptolysin O titer 4.Elevated erythrocyte sedimentation rate

4. Elevated erythrocyte sedimentation rate

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse? 1.Notify the nursing supervisor. 2.Contact the respiratory therapist. 3.Place the infant in a prone position. 4.Place the infant in a knee-chest position.

4. Place the infant in a knee-chest position.

A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1.During sleep 2.When changing the infant's diapers 3.When the mother is holding the infant 4.When drawing blood for electrolyte level testing

4. When drawing blood for electrolyte level testing

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1.Retake the apical pulse. 2.Administer the medication. 3.Withhold the medication for 1 hour. 4.Withhold the medication and notify the primary health care provider.

4. Withhold the medication and notify the primary health care provider. The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the primary health care provider. Retaking the apical pulse is not indicated given the context of the other findings in this question. Administering the medication could potentially cause harm. Withholding the medication for 1 hour does not address the problem of toxicity.

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1."The child may return to school in 1 week." 2."The child will not be able to return to school during this academic year." 3."The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4."The child may return to school in 3 weeks but needs to go half-days for the first few days."

4."The child may return to school in 3 weeks but needs to go half-days for the first few days."

While caring for a 14 month old diagnosed with Kawasaki disease, the registered nurse (RN) knows which clinical manifestation confirms this diagnosis? Select all that apply. a. recent history of headache and eye strain b. fever unresponsive to antipyretics c. cervical lymphadenopathy d. reddened skin rash with peeling e. strawberry tongue and red, cracked lips

b. fever unresponsive to antipyretics c. cervical lymphadenopathy d. reddened skin rash with peeling e. strawberry tongue and red, cracked lips

Realizing that cardiac manifestations are the most critical presentation of rheumatic fever, which assessment finding will the registered nurse (RN) expect to assess in the 6 year old client? Select all that apply. a. increased blood pressure, especially at night b. decreased force in peripheral pulses c. muffled heart sounds d. apical systolic murmur e. tachycardia irrelevant to activity

c. muffled heart sounds d. apical systolic murmur e. tachycardia irrelevant to activity