Pediatric Perfusion and PPH ADN 420

A child has been admitted to the inpatient unit to rule out acute Kawasaki disease. A series of laboratory tests have been ordered. Which findings are consistent with this disease? Select all that apply.

Reduced hemoglobin levels Elevated erythrocyte sedimentation rate (ESR)

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 client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased.

A client in the intensive care unit is diagnosed with hypovolemic shock based on a blood pressure of 88/53 mm Hg, heart rate of 122 beats/min, respiratory rate of 26 breaths/min. Given these vital signs, what urine output should the nurse expect?

Decreased below 30 mL/hr with decrease glomerular filtration rate (GFR).

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 collecting data on a 5-year-old child admitted with the diagnosis of congestive heart failure. Which clinical manifestation observed during the physical assessment would be consistent with this diagnosis?

Failure to gain weight

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m.

In an acute care setting, the nurse is assessing an unstable client. When prioritizing the client's care, the nurse should recognize that the client is at risk for hypovolemic shock in which of the following circumstances?

Fluid volume circulating in the blood vessels decreases.

A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's bestrecommendation to the parent?

Have the child be seen by the primary care provider.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV administration of lactated Ringer's

The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

Maternal tachycardia and falling blood pressure

A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action?

Obtain STAT hemoglobin and group and match.

The nurse is caring for a 6-year-old 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.

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

Place the client in a modified Trendelenburg position.

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant?

Rheumatic fever

A teenager is seen in the emergency room with reports of a sore throat, headache, fever, abdominal pain, and swollen glands. His mother tells the nurse that he was seen 3 weeks before in the clinic and treated with antibiotics for strep throat. He was better for a few days but now he seems to have gotten worse in the last 2 days. What should the nurse suspect is wrong with this client?

Rheumatic fever

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

Serum potassium level

A mother asks why her infant with a cyanotic heart defect turns blue. What is the nurse's bestexplanation?

This is due to a decreased amount of oxygen to the peripheral tissue.

Parents are told that their infant has a heart defect with a left-to-right shunt. What is the best way for the nurse to explain this type of shunting to the parents?

This type of shunting causes an increase of blood to the lungs.

Which assessment finding would be suggestive of adequate tissue perfusion in a client who has experienced a postpartum hemorrhage?

Urinary output of 60 cc's over the last hour

The nurse in a rural nursing outpost will be receiving a client in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. What principle should guide the nurse's administration of intravenous fluid?

Whatever fluid is most readily available in the clinic should be given, due to the nature of the emergency

A 10-year-old child is admitted to the hospital with a temperature of 104°F (40°C) and is difficult to arouse. The child has history of Varicella two weeks ago. Reye's syndrome is suspected. Which objective data is supportive of the diagnosis? Select all that apply.

an abnormal liver biopsy vomiting coma disorientation

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus.

The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication?

hypovolemic shock

The parents of a 13-year-old boy with a sore throat for a week, vomiting for two days, swollen lymph glands, and stiff achy joints is now seeking antibiotic treatment after herbal remedies were unsuccessful. Throat cultures reveal infection with group A streptococci. This child is at high risk for development of which cardiac complicaton?

mitral valve stenosis

A nurse is caring for a client with a new diagnosis of rheumatic fever. What is the highest prioritygoal of treatment during the acute phase?

prevent cardiac complications

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony