Peds PrepU Quizzes Ch. 19

The nurse is assessing the past medical history of an infant with a suspected cardiovascular disorder. Which response by the mother warrants further investigation?

"I am on a low dose of steroids." Explanation: Some medications, like corticosteroids, taken by pregnant women may be linked with the development of congenital heart defects. Reports of nausea during pregnancy and an Apgar score of 8 would not trigger further questions. Febrile illness during the first trimester, not the third, may be linked to an increased risk of congenital heart defects

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings?

"Your daughter has an innocent heart murmur, which is nothing to worry about." Explanation: The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.

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 BPM Explanation: Because digoxin slows the heart rate, it is important that it is not already beating at a slow rate before administration.

The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply.

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: The adolescent with an apical pulse under 60 beats per minute, the child with a digoxin level above 2 ng/mL, and the child who exhibiting signs of digoxin toxicity.

The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding?

90/64 mm Hg Explanation: The toddler's or preschooler's blood pressure averages 80 to 100/64 mm Hg. The normal infant's blood pressure is about 80/40 mm Hg. The school-age child's blood pressure averages 94 to 112/56 mm Hg. An adolescent's blood pressure averages 100 to 120/50 to 70 mm Hg.

The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention?

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.

The nurse is assessing a child with suspected rheumatic fever. What assessment findings are consistent with the disease process? Select all that apply.

Involuntary limb movement Macular rash on trunk Tender swollen joints Explanation: Signs and symptoms of rheumatic fever include systolic murmur, involuntary limb movement, macular rash on the trunk, tender swollen joints, and subcutaneous nodules.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?

It will determine if the heart is enlarged. Explanation: Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

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 Explanation: Edema of the lower extremities is characteristic of right ventricular heart failure in older children. In infants, peripheral edema occurs first in the face, then the presacral region, and the 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. Explanation: The nurse should pay particular attention to assessing the child's peripheral pulses, including pedal pulses. Using an indelible pen, the nurse should mark the location of the child's pedal pulses as well as document the location and quality in the child's medical records.

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

The nurse is caring for a 3 month old with history of congenital heart disease. The infant is brought to the emergency department with nausea and vomiting for 3 days. Admission labs confirm dehydration. The nurse realizes that the dehydrated infant is at risk for:

a cerebrovascular accident. Explanation: Children who have polycythemia from cardiovascular disease can develop thrombi if they become dehydrated.

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

bounding pulse A bounding pulse is characteristic of patent ductus arteriosis 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.

When a child is scheduled for a cardiac catheterization, an important health teaching point for parents is that the:

child will return with a bulky pressure dressing over the catheter insertion area. Explanation: Cardiac catheterization is typically performed with the child awake but using conscious sedation. A dressing will be placed on the catheter insertion site.

Tetralogy of fallot

pulmonary stenosis, ventricular septal defect (usually large), dextroposition (overriding) of the aorta, and hypertrophy of the right ventricle.