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

A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which statement by his mother may necessitate rescheduling of the procedure?

"He seems listless and slightly warm" Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should address the child's fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. Not using any medication would not be a reason for rescheduling the procedure.

The nurse is reviewing nutritional recommendations with the parents of a teen diagnosed with hyperlipidemia. Which statements indicate an understanding of the recommended diet for this condition? Select all that apply.

"I should plan to have vegetables with each evening meal served." "Adding fresh fruits to my child's lunch is a good idea." "My child loves chicken and I can still serve it but I need to remove the skin." Hyperlipidemia refers to high levels of lipids (fats/cholesterol) in the blood. High lipid levels are a risk factor for the development of atherosclerosis, which can result in coronary artery disease, a serious cardiovascular disorder occurring in adults. Dietary management is the first step in the prevention and management of hyperlipidemia in children older than 2 years of age. The diet should consist primarily of fruits, vegetables, low-fat dairy products, whole grains, beans, lean meat, poultry, and fish. As in adults, fat should account for no more than 30% of daily caloric intake. Fat intake may vary over a period of days, as many young children are picky eaters. Limit saturated fats by choosing lean meats, removing skin from poultry before cooking, and avoiding palm, palm kernel, and coconut oils as well as hydrogenated fats.

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" 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.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?

"It's great that you are providing nutritious meals, but smaller frequent meals will tire your child less and promote weight gain" Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child. Questioning if the parents are making nutritious foods or foods the child likes does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.

A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction?

"My child cannot have any thing to eat or drink after midnight the day of the test." Ambulatory electrocardiographic monitoring (Holter) testing is an exam that spans approximately 24 hours. The test is done to review the activity of the heart. The child is encouraged to follow one's normal activities during the test. There is no need for the child to be NPO prior to or during the test.

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." 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 what is happening to the parents. 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.

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" 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.

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" For a child with rheumatic fever, drug therapy must be given for the full *10 to 14 days* to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, *prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old*. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

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." With the Gore® Helex device, strenuous activity should be avoided for 2 weeks after the procedure, so neither soccer or bicycle riding would be allowed. Children should be monitored for the possible presence of atrial arrhythmias (lifelong) after surgical closure for the defect. Infection is a complication that must be monitored for and reported to the physician, and medications must be given 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" 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 pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can do to reduce the risk of this type of condition occurring in her baby. What information should the nurse mention to this client?

"make sure you are fully immunized" The cause of congenital heart disease often cannot be documented, although it is associated with familial patterns of inheritance and possibly triggers such as rubella (German measles) and varicella (chickenpox) infection during pregnancy. Women need to enter pregnancy fully immunized to help prevent infection during pregnancy. Encouraging the child to eat a low-sodium diet and exercise as he or she grows up will help prevent acquired heart disease, not congenital heart disease.

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 and connected to the heart and will detect if your infant's heart gets out of rhythm" Following cardiac repair there is always a possibility of arrhythmias. The wires are placed and connected to an external pacemaker. This is done as a preventive measure and can be used if an arrhythmia occurs. Once it is felt the child is in no danger of an arrhythmia, the wires are removed. There is no set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization.

The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant's body weight. The infant weighs 15.2 lb (6.9 kg). Calculate the infant's morphine sulfate dose. Record your answer using one decimal place.

0.7 The does should be calculated weight in kilograms. The infant weighs 6.9 kg. For each kilogram of body weight, the infant should receive 0.1 mg of morphine sulfate. 6.9 kg x 0.1 mg/1 kg = 0.69 mg. Rounded to the tenth place = 0.7 mg. The infant will receive 0.7 mg of morphine sulfate.

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 beats per minute Digoxin is a cardiac glycoside that works by increasing the contractility of the heart muscle. It decreases conduction and increases the force of the heart beat. The result is a slowing of the heart rate. An 8-month-old infant has a normal range of heart rate of 80 to 150 beats per minute while awake and resting, and 80 to 130 beats per minute while sleeping. The accepted practice for this age child is to withhold the digoxin if the heart rate is 90 beats per minute or less. It would be safe to administer the drug if the heart rate is 100 beats per minute. If the child has a heart rate of 150 beats per minute, further assessment should be made prior to administering the drug.

The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy?

100 to 120/70 to 80 mm Hg The normal adolescent's blood pressure averages 100 to 120/70 to 80 mm Hg. The average infant's blood pressure is about 80/55 mm Hg. The toddler or preschooler's blood pressure averages 90 to 110/55 to 75 mm Hg. The normal school-ager's blood pressure averages 100 to 120/60 to 75 mm Hg.

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 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.

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 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 if the apical pulse is less than 60 in an adolescent, less than 90 in an infant.

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

90/64 The toddler or preschool-age child'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 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. When a newborn with patent ductus arteriosus shows signs of significant blood flow to lungs (retractions, crackles, tachypnea, and hypoxia), nursing actions will focus on applying oxygen to improve oxygenation and decrease work of breathing. Nursing interventions also include reducing cardiac workload and pulmonary flow by initiating intravenous access to administer a diuretic to reduce extra fluid and indomethacin to cause closure of the PDA and stop increased pulmonary blood flow. Feeding the infant is not a priority at this time as aspiration may result from the inability to coordinate sucking and swallowing with increased work of breathing.

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. Total cholesterol levels below 170 mg/dl and LDL levels less than 100 mg/dl are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dl and LDL levels greater than or equal to 130 mg/dl are considered elevated and place this child at greatest risk.

The nurse is educating an adolescent female at risk for hypertension. Which interventions will the nurse recommend? Select all that apply.

Increase hours of sleep. Avoid any smoking. Exercise on a daily basis. Maintain a healthy weight. Increasing the hours of sleep, daily exercise, avoiding smoking, and maintaining a healthy weight are all recommended interventions to prevent hypertension in the adolescent. An adolescent at risk for hypertension would not need a beta-blocker. Medication would be used for an adolescent with hypertension that did not improve after less invasive interventions.

The nurse is caring for a child who is preparing to undergo an exercise stress test. Which interventions will be included in the care?

Monitor vital signs prior to the start of the test. Monitor vital signs at completion of the test. Remind child to verbalize any feelings of discomfort during the test. The exercise stress test monitors heart rate, blood pressure, ECG, and oxygen consumption at rest and during exercise. Vital signs are taken prior to, during and after the test period. An EKG is taken prior to the test. Serum glucose levels are not associated with this test.

A health care provider and other health team members are discussing congenital heart disorders that increase pulmonary blood flow. Which disorders are topics for this discussion? Select all that apply.

Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect

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

a cerebrovascular accident (stroke) Children who have defects that cause decreased pulmonary blood flow have decreased oxygen saturation. To compensate, the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells. The increased red blood cells makes the blood more viscous. If an infant with heart disease becomes dehydrated the infant can develop thrombi from the increased amounts of red blood cells and the viscosity of the blood. This places the infant at risk for a cerebrovascular accident (stroke). Jaundice would only occur if the liver was involved. Tachycardia and seizures can occur with dehydration but an infant with a congenital heart defect would be at a higher risk for a cerebrovascular accident.

Which nursing diagnosis would best apply to a child with rheumatic fever?

activity intolerance due to the inability of the heart to sustain extra workload Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.

A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant?

administer oxygen 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 caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate?

apply pressure 1 inch above the site If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.

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

aspirin Medications used in the treatment of rheumatic fever include penicillin, salicylates (aspirin), and corticosteroids. Insulin would be given for diabetes and dilantin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

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 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.

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?

assessing for the presence of femoral pulses Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.

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 Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

What information would be included in the care plan of an infant in heart failure?

begin formulas with increased calories 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.

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 arteriosus 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.

The nurse is collecting data on a child being evaluated for rheumatic fever. The caregiver reports that over the past several weeks the child seems to have lack of coordination, facial grimaces and repetitive involuntary movements. Based on these symptoms the nurse would suspect what condition?

chorea Rheumatic fever affects the heart, the central nervous system, skin and subcutaneous tissue. It causes carditis, arthritis, and chorea. Chorea is a disorder characterized by emotional instability, purposeless movements, and muscular weakness. The onset of chorea is gradual, with increasing incoordination, facial grimaces, and repetitive involuntary movements. Polyarthritis means there is arthritis in multiple joints which is common in rheumatic fever, but this is not a symptom of chorea. Arthralgia is a very common symptom of rheumatic fever. It is pain in the joints but again not a symptom of chorea. The heart muscle is affected in rheumatic fever as are the valves but not included in the symptoms of chorea.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?

digoxin 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.

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 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.

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 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.

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:

femoral pulse weaker than brachial pulse A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.

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

have the child be seen by the primary care provider Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

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 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, irritability are signs of Kawasaki disease.

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 Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. An echocardiogram involves high-frequency sound waves, directed toward the heart, being used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers; thickness of walls; relationship of major vessels to chambers; and the thickness, motion, and pressure gradients of valves. You can remind parents that echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

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 RBC 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 tissue perfusion related to inefficiency of the heart as a pump 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 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 A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later.

A 6-year-old girl is diagnosed with pulmonary 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 undefeated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions Balloon angioplasty by way of cardiac catheterization is the procedure of choice for pulmonary stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and relieves the stenosis. The other answers refer to interventions related to patent ductus arteriosus, not pulmonary stenosis.

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 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*.

When caring for a child with Kawasaki disease, the nurse would know that:

management includes the administration of aspirin and IVIG Kawasaki disease is an acute systemic vasculitis. It is the most common form of acquired heart disease in children. The treatment is directed to reduce the inflammation in the walls of the coronary arteries and prevent thrombosis. Children are given high-dose aspirin therapy four times a day and they receive an infusion of IV immunoglobulins (IVIG) to prevent cardiac complications. Joint pain is common but not necessarily a permanent problem associated with Kawasaki disease. Antibiotics and steroid creams are not used to treat this disorder.

The nurse is auscultating heart sounds of a child with a mitral valve prolapse. The nurse should expect which assessment finding?

mild to late ejection click at the apex

A nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin?

nausea and vomiting Digoxin is a cardiac glycoside and antiarrhythmic. It can cause toxicity if the dosages increase due to poor absorption, dehydration, etc. Signs of digoxin toxicity are nausea and vomiting, lethargy, and bradycardia. The apical pulse should be taken for one full minute prior to administering digoxin. The dosage should be held if the pulse rate is less than 60 beats/min in an adolescent or less than 90 beats/min in an infant. The other symptoms listed do not relate to digoxin toxicity and could occur for numerous reasons.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

notify the doctor immediately The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

peeling hands and feet; fever Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.

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 priority nursing action is to place the infant or 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 ordered. A calm, comforting approach should be used but is not the priority action. Once a child is placed in the knee-to-chest position, supplemental oxygen would be provided as ordered. Once a child is placed in the knee-to-chest position, medications would be given as ordered.

What would be the most important measure to implement for an infant who develops heart failure?

placing the infant in a semi-fowlers position 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.

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

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

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.

providing supplemental oxygen giving parenteral morphine sulfate 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).

A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta?

pulses weaker in lower extremities compared to upper extremities With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased systemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses. Coarctation is not a cyanotic defect. The cyanosis would be associated with tetralogy of Fallot.

Which nursing diagnosis will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

risk for ineffective cardiopulmonary tissue perfusion Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and anxiety will be monitored after ensuring cardiopulmonary tissue perfusion is adequate.

The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority?

swab throat for culture A child with generalized joint pain, pharyngitis, and murmur is exhibiting signs of rheumatic fever. A priority action is to obtain a throat culture to verify presence of a group A streptococcus infection and then administer penicillin. Assessing for a rash is minimally helpful as there is enough assessment data to obtain a throat culture. A high C-reactive protein is an indicator of an active infection, but it will not identify the source of the infection and the necessary pharmacologic therapy.

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

tachycardia 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.

At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?

taking pedal pulses for the first hours Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

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

tetralogy of fallot 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.

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

the child will need the blood pressure checked two more time The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.

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 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 providing education to parents of a child with a blood pressure in the 90th percentile. What would be included in the intervention strategies?

the nurse would review the child's 24 hour diet recall With a child in the 90th percentile for blood pressure, diet and physical activity should be the main focus. Blood pressures should be measured but daily measurement is not necessary. Children are not routinely put on beta-blockers, and the child should be allowed to participate in sports if monitored.

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 closed by 1 week of age 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.

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 This type of shunting causes an increase of blood to the lungs. A right-to-left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason?

to build the blood levels to a therapeutic level The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?

wheezing The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset, nausea, and abdominal distress are common with oral antibiotics and do not need to be reported immediately.