FINAL PED CHAPTER 19
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? "The feeling of the heart skipping a beat is common." "We need to avoid a tub bath for the next 3 days." "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.
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." "Increased cardiac workload from your toddler's heart defect affects various parts of the body, including the fingers." "The number of red blood cells has significantly increased from the heart defect, resulting in the cells pooling in the fingertips." "This is a common complication of tricuspid atresia. Unfortunately, there is nothing we can do to treat it."
"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." Explanation: Clubbing (which is what the parents are describing) of fingertips or toes can occur from the chronic hypoxia that occurs with disorders with decreased pulmonary blood flow, such as tricuspid atresia. Using the term "low oxygen levels in the blood" rather than "chronic hypoxia" is a better way to explain to the parents what is happening with their child. Clubbing is not the result of increased cardiac workload. Red blood cell pooling is not the cause of clubbing. Although clubbing is a possible result of tricuspid atresia, telling the parents this is a "common complication" does not address the parent's concerns.
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. "Our child will be so excited to get back to soccer league in a few days." "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "It's wonderful that our child will never have an abnormal heart rhythm again." "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."
"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."
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." "Your daughter has a functional heart murmur; I recommend that you limit her physical activity so that her heart rate is not elevated for long periods of time." "Your daughter has an organic heart murmur, which indicates that she has some degree of heart disease. The doctor will provide a referral to a good cardiologist." Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her.
"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.
A nurse is caring for an infant with a cyanotic heart defect. Which of the following symptoms would indicate risk for congestive heart failure?
1. Respiratory crackles and frothy secretions 4. Hepatomegaly 5. Rapid weight gain
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? 60 beats per minute 80 beats per minute 100 beats per minute 150 beats per minute
100 beats per minute
The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply. 4-month-old child with an apical heart rate of 102 beats per minute 12-year-old child whose digoxin level was 0.9 ng/ml on a blood draw this morning 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
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? 118 beats/min 102 beats/min 94 beats/min 80 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.
The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of the great vessels? a. Significant cyanosis without presence of a murmur b. Abrupt cessation of chest output with an increase in heart rate/filling pressure c. Soft systolic ejection d. Holosystolic murmur
ANS: A Feedback: Significant cyanosis without presence of a murmur is highly indicative of transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic murmur can be found with other disorders, such as hypoplastic left heart syndrome, but is not highly suspicious of transposition.
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? a. Contact the healthcare provider. b. Offer a snack and administer another dose. c. Immediately administer another dose. d. Administer next dose as ordered in 12 hours.
ANS: D Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should not give a second dose and should wait until the next scheduled dose. It is not necessary to contact the healthcare provider.
A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant? Administer antidiuretic. Provide large, less frequent feedings. Restrict fluids. Administer oxygen.
Administer oxygen. Explanation: If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.
The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first? Contact the health care provider. Apply appropriate oxygen device. Prepare for balloon angioplasty. Assess blood pressure in all extremities.
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.
What information would be included in the care plan of an infant in heart failure? Encourage larger, less frequent feedings. Begin formulas with increased calories. Maintain child in the supine position. 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.
The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level? Digoxin Albuterol sulfate Ferrous sulfate Spironolactone
Digoxin Explanation: The use of large doses of digoxin at the beginning of therapy to build up the blood levels of the drug to a therapeutic level is known as digitalization. During the 24 hours digitalization is occurring, the child should be on a cardiac monitor and the nurse should monitor the PR interval and a decreased ventricular rate. The other listed medications are not administered in this manner. Albuterol is inhaled for asthma treatment and used primarily for exacerbations. Ferrous sulfate is give for iron-deficiency anemia, and spironolactone is a diuretic.
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? Digoxin Alprostadil Furosemide Indomethacin
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? Feeding problems Bradypnea Bradycardia Yellowish color
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 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? Increased WBC Decreased RBC Decreased WBC Increased RBC
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? Ineffective airway clearance related to altered pulmonary status Ineffective tissue perfusion related to inefficiency of the heart as a pump 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 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.
The primary health care provider has prescribed intravenous furosemide for a child diagnosed with congestive heart failure (CHF). Which action will the nurse take when administering this medication? Administer with 10% dextrose solution. Infuse no more than 4 mg per minute. Monitor respirations during administration. Assess glucose levels.
Infuse no more than 4 mg per minute. Explanation: Diuretics such as furosemide, along with fluid restriction in the acute stages of CHF, help to eliminate excess fluids in the child with congestive heart failure. The nurse would administer no more than 4 mg of IV furosemide per minute to prevent ototoxicity. Furosemide should be diluted in D5W, NS, or LR solutions. Respirations should be monitored frequently in this client, but it is not necessary to monitor while administering the medication. Glucose levels should be monitored in clients with diabetes only.
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. Use a calm, comforting approach. Provide supplemental oxygen. Administer morphine as prescribed.
Place the child in a knee-to-chest position. 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.
When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? Leukopenia Polycythemia Increased platelet level Anemia
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.
Which collaborative action(s) will the nurse perform when caring for an infant with transposition of the great arteries scheduled for surgical repair of the defect? Select all that apply. Provide education to the parents. Auscultate lung sounds frequently. Apply a continuous pulse oximeter. Keep oxygen saturation above 80%. Administer indomethacin intravenously.
Provide education to the parents. Auscultate lung sounds frequently. Apply a continuous pulse oximeter. Keep oxygen saturation above 80%. Explanation: Collaborative interventions for an infant with transposition of the great arteries include providing education to parents in preparation for their infant's surgery; assessing pulse oximetry and auscultating lung sounds frequently to monitor for signs of increased pulmonary flow; and maintaining normal oxygen saturation for transposition of the great arteries at approximately 80%. Administering indomethacin would cause closure of the ductus arteriosus, which would prevent mixing of blood.
A nurse is developing the plan of care for a 7-year-old child diagnosed with congenital heart disease and a history of hypercyanotic spells. Which interventions would the nurse include in the child's plan of care to address these spells? Select all that apply. Place the child in the orthopneic position. Provide supplemental oxygen. Administer oral fluids as prescribed. Give parenteral morphine sulfate. Encourage increased activity.
Provide supplemental oxygen. Give parenteral morphine sulfate. Explanation: For a child experiencing a hypercyanotic spell, the nurse should use a calm, comforting approach and place the child in a knee-to-chest position, provide supplemental oxygen, administer morphine sulfate (0.1 mg/kg IV, IM, or SQ), supply IV fluids, and administer propranolol (0.1 mg/kg IV).
When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure? Tachycardia Bradycardia Inability to sweat Splenomegaly
Tachycardia Explanation: Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.
A nurse is providing education to a family about cardiac catheterization. What information would be included in the education? The catheter will be placed in the femoral artery. The catheter will be placed in the brachial artery. The child will be able to move the leg again immediately after the procedure. The procedure will be performed even if the child has a fever.
The catheter will be placed in the femoral artery. Explanation: A cardiac catheterization can be performed via the right side of the heart or the left side. If the catheter is going through the right side it would be inserted into the femoral vein and threaded to the right atrium. If it is going to the left side the catheter would be threaded through the femoral artery to the aorta. The child will need to lie still for 4 to 6 hours with the leg outstretched after the procedure to prevent bleeding. The brachial artery is not used. The procedure is usually postponed if the child has a fever.
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 spleen size increases due to frequent infection. The liver size increases in right-sided heart failure. 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 mother asks the nurse if the reason the infant has a congenital heart defect is because of something she did while pregnant. What is the best response by the nurse? There are several reasons an infant can have a heart defect; let's talk about those causes. Yes, there is a chance you caused this defect. No, heart defects are mainly caused by genetic factors. The studies show it is impossible to know what causes heart defects.
There are several reasons an infant can have a heart defect; let's talk about those causes. Explanation: Parents who have a newborn who has a defect are always concerned they did something wrong to cause the defect. They carry a large amount of guilt. The nurse should focus on the therapeutic communication in this situation, while still obtaining more information. A nurse should never blame the parent because it is not only nontherapeutic, but there are many reasons why congenital heart defects occur. The reason for the infant's heart defect may not be known. Using therapeutic communication will reduce the parent's anxiety and guilt. Congenital heart defects can be caused by genetic defects such as chromosomal anomalies but this is not always the case.
A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education? Your child may need multiple surgeries to correct this defect. An IV for fluids will be started immediately. This is caused by an opening that usually closes by 1 week of age. This type of defect is caused by having a genetic predisposition for it.
This is caused by an opening that usually closes by 1 week of age. Explanation: A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.
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. This noninvasive test will check the electrical impulses in the heart. This test will only determine the size of the heart. This invasive test will measure the blockage in the heart.
This test will check how blood is flowing through the heart. Explanation: An echocardiogram (echo) is a noninvasive ultrasound used to assess the heart wall thickness, the size of the heart chambers, the motion of the valves and septa, and the relationship of the great vessels to other cardiac structures. The test evaluates how blood is flowing through the heart and how effective the heart is in pumping. An echo does not check the electrical impulses. This would be done with an electrocardiogram.
Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? surgical site infection risk acute parental anxiety fluid overload 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.
When caring for a child who has just had a cardiac catheterization, what is a sign of hypotension? cold, clammy skin and increased heart rate decreased heart rate and dizziness syncope and tachypnea diaphoresis and tachycardia
cold, clammy skin and increased heart rate Explanation: Cold, clammy skin; increased heart rate; and dizziness are signs of hypotension that may be a complication after a cardiac catheterization. Decreased heart rate, syncope, and tachypnea would also be very concerning, but not necessarily a sign of hypotension.
The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder? heart failure infective endocarditis cardiomyopathy Kawasaki Disease
heart failure Explanation: Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, and irritability are signs of Kawasaki disease.
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 face presacral region hands
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.
A newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the mother, which defect would the nurse's description include? atrial septal defect stenosis of the aorta overriding of the aorta left ventricular hypertrophy
overriding of the aorta Explanation: One of the components in the tetralogy of Fallot is the overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with four components include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta, and left ventricular hypertrophy are not components of tetralogy of Fallot.
What would be the most important measure to implement for an infant who develops heart failure? restricting milk intake daily planning ways to reduce salt intake placing the infant in a semi-Fowler position keeping the infant supine and playing quiet games
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 child has been prescribed spironolactone. Which laboratory values should be reviewed when following up on this medication? Select all that apply. serum potassium levels serum sodium levels serum chloride levels serum magnesium levels serum calcium levels
serum potassium levels serum sodium levels Explanation: Spironolactone is a potassium-sparing diuretic that competes with aldosterone to result in increased water and sodium excretion (spares potassium). It is used to manage edema due to heart failure and for treatment of hypertension. Serum potassium and sodium levels should be evaluated in someone taking this medication.
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? steady weight gain since birth softening of the nail beds appropriate mastery of developmental milestones intact rooting reflex
softening of the nail beds Explanation: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? coarctation of aorta tetralogy of Fallot pulmonary stenosis 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.
After a cardiac catheterization, the nurse monitors the child's fluid balance closely based on the understanding that: the contrast material used has a diuretic effect. blood loss during the procedure can be significant. the insertion of the catheter into the heart stimulates a diuretic response. the prolonged preprocedure fasting state places the child at risk for dehydration.
the contrast material used has a diuretic effect. Explanation: The contrast material has a diuretic effect so the nurse assesses the child closely for signs and symptoms of dehydration and hypovolemia. Although blood loss can occur, this is not the reason for monitoring the child's fluid balance. Catheter insertion into the heart does not initiate a diuretic response. Typically, food and fluid is withheld for 4 to 6 hours before the procedure.
