Ch 41 PrepU: Child w/ cardiovascular disorder

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?

increase 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).

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

"Children who have this diagnosis may have had strep throat." Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

The parents of a 10-year-old boy bring the child to the clinic for an evaluation. Which statement by the parents would alert the nurse to the possibility of rheumatic fever?

"He had a pretty bad sore throat about 10 days ago." Rheumatic fever is an autoimmune disease that occurs as a reaction to a group A beta-hemolytic streptococcal infection, specifically, a pharyngitis. Inflammation from the immune response leads to inflammatory lesions in the heart, blood vessels, brain, and joints. A child with rheumatic fever typically has a higher fever than that reported by the parents in this scenario. A macular rash (not a white thick coating of the tongue) found predominantly on the trunk is an infrequent symptom but if seen is a virtually definitive sign of rheumatic fever. A complaint of feeling tired is a nonspecific symptom.

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." 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 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?

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.

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

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.

The nurse is caring for a newborn in the hospital. Which assessment finding is most concerning?

A fixed split-S2 can be indicative of right heart volume overload and is seen with an atrial septal defect. Acrocyanosis (bluish tint to the hands and/or feet) is a normal finding in the newborn; although the hands should not feel cool, this finding is not as concerning as a fixed split-S2. Although an abnormal finding, a high-pitched systolic murmur is a common innocent murmur of infancy related to the turbulent flow of blood through the pulmonary arteries. A respiratory rate of 62 breaths per minute is also abnormal, but it may be related to the newborn's transition to extrauterine life, and it is not as concerning as a fixed split-S2.

The nurse is implementing the plan of care for a child with acute rheumatic fever. What treatment(s) would the nurse expect to administer if prescribed? Select all that apply.

A full 10-day course of an antibiotic, such as penicillin or equivalent, is used. Anti-inflammatory agents, such as corticosteroids and nonsteroidal anti-inflammatory drugs, are also used in the treatment of acute rheumatic fever. Digoxin, an antiarrhythmic agent, a is used to treat heart failure, atrial fibrillation, atrial flutter, and supraventricular tachycardia. Intravenous immunoglobulin, an immunoglobulin therapy, is used to treat Kawasaki disease.

After assessing a child's blood pressure, the nurse determines the pulse pressure and finds that it is narrowed. What would the nurse identify as associated with this finding?

A narrowed pulse pressure is associated with aortic stenosis. A widened pulse pressure is associated with patent ductus arteriosus, aortic insufficiency, fever, anemia, or complete heart block.

In caring for the child with rheumatic fever, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?

Acute pain related to joint pain when extremities are touched or moved is a concern for the child with rheumatic fever. Diversional activities are important, but growth and development is not likely to be delayed. Chorea may be frustrating to the child but body image is not altered. Respiratory issues are not noted with rheumatic fever.

Nursing students are reviewing information about cardiopulmonary arrest in children. They demonstrate an understanding of the information when they identify which of the following as the most common cause of cardiac arrest?

Although cardiopulmonary arrest may result from trauma, anaphylaxis, or drowning, respiratory failure is the most frequent cause of cardiac arrest.

A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, what would the nurse most likely include?

An echocardiogram is a noninvasive ultrasound procedure using a gel-coated wand that assesses the heart wall thickness, the size of the chambers, valve and septal motion, and the relationship of the great vessels to other cardiac structures. An electrocardiogram reveals the pattern or rhythm of the heart's beating and involves small patches or electrodes attached to the chest. A chest radiograph involves a radiographic film of the chest to determine the size of the heart and its chambers.

The nurse is developing a plan of care for a child diagnosed with rheumatic fever. Which nursing intervention should the nurse prioritize for this child?

As long as the rheumatic process is active, progressive heart damage is possible. To prevent heart damage, bed rest is essential to reduce the heart's workload. Laboratory tests for erythrocyte sedimentation rate (ESR) and C-reactive protein can be used to evaluate disease activity and guide treatment, but they do not improve the child's health. The child's comfort is important, so it is essential to relieve joint pain and prevent injury with padded bed rails. But these measures are less important than rest when it comes to preventing long-term complications such as residual heart disease.

The nurse will administer what medication to children with Kawasaki disease both in the acute and later stages of the illness?

Aspirin is important in reducing the inflammation of Kawasaki disease as well as helping to limit platelet aggregation. Larger doses are given during the acute process and smaller doses during the convalescent period. Intravenous immune globulin (IVIG) is a medication given immediately on diagnosis. The other medications are not appropriate.

A child with a congenital heart defect comes to the clinic with flu-like symptoms, parental report of not eating, and weight loss. What assessment(s) should the nurse complete for this child? Select all that apply.

Assess: temp, abdomen, heart sounds, and conjunctiva color. The child is showing symptoms of infective endocarditis. It would be important for the nurse to assess any flu-like symptoms (myalgia, arthralgia, night sweats) and intermittent low-grade fevers. It would be important for the nurse to know the child's history of the type of congenital heart defect, any valvular disorders, or heart failure. If heart failure is known, then the nurse should assess for edema. The nurse should assess the heart sounds for a new or a changing murmur. The nurse should assess the abdomen for splenomegaly. The nurse should auscultate lung sounds for any adventitious sounds. The nurse would only assess skin turgor if dehydration is suspected. A simple way to check for anemia is to inspect the conjunctiva. If anemia is present, the conjunctiva will be very pale. Anemia can be confirmed by laboratory testing. In addition to direct assessment, an electrocardiogram will be performed. It will show a prolonged PR interval.

After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow?

Atrial septal defect is an example of a disorder involving increased pulmonary blood flow. Tetralogy of Fallot is a defect involving decreased pulmonary blood flow. Transposition of the great vessels and hypoplastic left heart syndrome are examples of mixed disorders.

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?

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.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary for their infant. How will the nurse respond?

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 electrocardiogram. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is magnetic resonance imaging.

A nurse is caring for a 6-month-old infant diagnosed with a congenital heart anomaly and awaiting a heart transplant. The nurse suspects the infant is experiencing right-sided heart failure. Place the findings in the order the nurse would expect to assess for an infant experiencing right-sided heart failure. Use all options.

Congestive heart failure can occur quickly in an infant with a congenital heart anomaly. The nurse must use assessment skills to be able to identify a trend in data that suggests impending cardiac failure. One of the first signs of congestive heart failure is tachycardia, as documented with a heart rate greater than 160 beats/min. This assessment finding is followed by tachypnea greater than the normal maximum of 50 breaths/min. Next, hepatomegaly occurs, causing the infant to feel irritable and restless from the abdominal pain from liver distention. Lower extremity edema, usually a primary sign in adults, is often a late sign in infants.

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

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.

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

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 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?

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.

A nurse is caring for a child who is experiencing heart failure. Which assessment data was most likely seen when initially examined?

If a child were experiencing heart failure, the most likely sign of this would be tachycardia, not bradycardia. The child may also experience hepatomegaly or oliguria, not splenomegaly or polyuria.

The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was:

In an infant, if the apical pulse rate is less than 90 beats per minute, the dose is held and the physician should be notified.

An infant with congenital heart disease is not growing and developing adequately. The nurse will institute what feeding strategy?

Increasing the caloric density of the feeding allows the infant to ingest more calories without increased volume and in a shorter period of time. This conserves energy. Calories per ounce can be increased by adding supplements to pumped breast milk. Using commercial formula could be necessary if a special formula is needed. However, breast milk is usually the infant's best source of nutrition. Feeding the infant every 2 hours and increasing the length of the feeding beyond 30 minutes will fatigue the child and allow for little rest between feedings.

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

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.

After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding?

Jerky movements of the face and upper extremities. Sydenham chorea is a movement disorder of the face and upper extremities associated with acute rheumatic fever. Janeway lesions, black lines, and Osler nodes are associated with infective endocarditis.

A nurse is developing a plan of care for a child who has had open-heart surgery with two chest tubes inserted. Which nursing actions(s) will the nurse perform when caring for the child's chest tubes? Select all that apply.

Keep the drainage system below the level of the child's chest and Ensure that all chest tube connections are secure.

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

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

A child is being placed on a cardiopulmonary bypass machine. The nurse understands the heart will pump again on its own when what occurs?

The child is placed in a hypothermic state when placed on a cardiopulmonary bypass. When the child is warmed, the heart starts pumping again.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

When assessing an infant born at 32 weeks' gestation, which finding would lead the nurse to suspect that the newborn has a patent ductus arteriosus (PDA)?

Presence of a continuous murmur on auscultation of the heart is indicative of patent ductus arteriosus (PDA) in preterm infants. Preterm infants are at an increased risk of developing PDA. Other assessment findings that indicate PDA include bounding pulse, increased pulse rate and low diastolic arterial pressure.

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.

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?

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.

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease?

Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily. Feeding every 4 hours will not promote the intake and growth required for an infant with CHD.

A newborn has been diagnosed with congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis?

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 the aorta, pulmonary stenosis, and aortic stenosis are a cyanotic heart diseases and are not associated with cyanosis.

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 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 cardiac nurse is examining a 10-year-old child with a documented heart murmur. On auscultation, the nurse assesses that the murmur occurs only during systole, is short, and sounds soft and musical. When the child is standing, the nurse can no longer hear the murmur upon auscultation. Upon completion of the assessment, which nursing action is appropriate?

The nurse would document the findings and state, "Your child has an innocent heart murmur, which is not a cause for concern." Following assessment of a previously documented heart murmur, the nurse is most correct to evaluate the murmur and document the findings. The symptoms identified by the nurse 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 or referrals to specialists. The nurse needs to be honest with the parents as the parents may be concerned with another nurse evaluating the child's cardiac function.

The nurse is caring for an infant prescribed oral digoxin. Which finding will cause the nurse to hold the dosage and notify the primary health care provider?

The nurse would hold the dosage if the infant's serum level is 4 ng/mL (5.12 nmol/L). The therapeutic range is 0.8 to 2 ng/mL (1.02 to 2.56 nmol/L). Prior to administering each dose, the nurse should count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The dose would be withheld if the apical pulse is less than 60 in an adolescent and less than 90 in an infant. The nurse would avoid giving oral digoxin with meals as altered absorption may occur. The normal respiratory rate for an infant is 30 to 60 breaths/minute.

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

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.

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?

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.

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?

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 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?

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 child returns from cardiac surgery with a central venous pressure catheter in place to monitor central venous pressure. The nurse would ensure that the manometer's zero point is at the level of which of the following?

The zero point of the central venous pressure manometer should be at the level of the right atrium.

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. 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 an infant with suspected patent ductus arteriosus. Which assessment finding would the nurse identify as helping to confirm this suspicion?

With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually loudest under the left clavicle) is heard at the first and second intercostal spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the left sternal border point to aortic stenosis.

A 10-week-old infant continues to have a small ventricular septal defect (VSD) and is prescribed digoxin. When evaluating the infant's response to drug therapy, which assessment finding is related to the therapeutic action of the medication?

a reduced fluid accumulation in the lungs Because up to 85% of VSDs are so small they close spontaneously, many children are managed only by close observation during the first years of life, perhaps with administration of a diuretic or digoxin to help prevent fluid from accumulating in the lungs. Placement of a septal occlude device during cardiac catheterization is done to prevent chronic pulmonary artery hypertension from developing or the heart from becoming infected (endocarditis) because of the recirculating and stagnant blood flow. Digoxin does not dilate arteries nor prevent infection or arrhythmia. The therapeutic effect is not to facilitate the closing of the defect.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

altered cardiopulmonary tissue perfusion risk 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.

A nurse is assessing a 6-year-old male child brought to the pediatrician's office for sore throat and fever. Assessment reveals lethargy; dry, warm skin; capillary refill time <3 seconds; lungs clear to auscultation. Vital signs: temperature, 100.1°F (37.8°C); heart rate, 128 beats/min; respiratory rate, 28 breaths/min. The nurse performs a throat culture, which is positive for group A streptococcus (GAS). Urine sample results: dark concentrated urine; urine specific gravity 1.04.

at risk of carditis due to strep A Acute rheumatic fever (ARF) is caused by an untreated group A streptococcus (GAS) infection. If left untreated, ARF causes an autoimmune inflammatory reaction that affects the heart and blood vessels. Because the child has tested positive for GAS, the child at high risk for developing symptoms of acute rheumatic fever, which include carditis if the infection is not treated. Untreated group A streptococcus is the primary cause of rheumatic fever in children 5 to 15 years of age. To prevent complications, the child will need to take a full course of antibiotics to eradicate the bacteria. Group A streptococcus (GAS) causes an inflammatory response that affects the heart and vessels, placing the child at risk for carditis, not acute kidney injury. There are no signs or symptoms that the child is at risk of developing pneumonia. A child with pneumonia would present with fever, productive cough, adventitious lung sounds such as crackles or rhonchi, and an elevated white blood cell (WBC) count. The child's lung sounds are clear to auscultation and respirations are regular. These are normal findings. The child's urine specific gravity is elevated at 1.04, indicating that the child is dehydrated. An increased urine specific gravity is not an indication of acute renal failure. Evidence of acute renal failure would include an elevated creatinine and blood urea nitrogen (BUN), and decreased urine output.

A 6-year-old girl had a cardiac catheterization at 9 a.m. At 11 a.m. the nurse notes hypotension as compared to baseline. Based on this assessment finding, which of the following would the nurse do first?

check insertion site Hypotension may signify hemorrhage due to perforation of the heart muscle or bleeding from the insertion site. Rechecking the blood pressure every 15 minutes is done during the first hour and then every 30 minutes for the next hour. Rechecking the blood pressure would be appropriate after the nurse checks the insertion site and determines that bleeding is not present. Pain or fever would be more likely with infection or thrombus formation. Pallor, diminished temperature, and altered capillary refill time in the affected extremity could signal compromised neurovascular status.

The nurse is planning care for an infant with a nursing diagnosis of decreased cardiac output related to a cardiac defect. What is the most appropriate outcome for this nursing diagnosis? The child will:\

demonstrate stable vital signs, capillary refill less than 3 seconds, and a urine output of 1-2 ml/kg/hr.

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 client's newborn is diagnosed with Tetralogy of Fallot. When explaining this condition to the client, which of the following defects would the nurse's description include?

overriding of the aorta One of the components in the Tetralogy of Fallot is overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with 4 components. The defects in the Tetralogy of Fallot 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.

A 1-year-old with tetralogy of Fallot turns blue during a temper tantrum. What will the nurse do first?

place child in knee to chest position Tetralogy of Fallot is a cyanotic heart defect. Hypercyanosis can develop suddenly. The symptoms are increased cyanosis, hypoxemia, dyspnea, and agitation. The nurse should use a calm, comforting approach with the child and place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. This position increases pulmonary blood flow by increasing systemic vascular resistance. The additional interventions for a hypercyanotic spell are to administer oxygen and give morphine, IV fluids, and propranolol. A child will not understand to calm down and cannot be expected to listen during a temper tantrum. Assessing the child's heart rate and respirations are not priority. Perfusion is priority for this client at this time.

The school nurse has assessed a 12-year-old child's blood pressure (HTN on 3 different dates). Based on these assessment findings, what will the nurse do next?

reassess the blood pressure in another visit A diagnosis of hypertension requires three separate elevated readings in three separate visits. Because two of these readings were taken in the same visit, the child should be asked to return for a third assessment of blood pressure in another visit. If hypertension is diagnosed, then informing the health care provider and referral to a family-based intervention program may be appropriate but not at this stage. Daily blood pressure assessments are not necessary.