HESI RN Congenital Heart Disease - Peds

The nurse asks Joan and Thomas if they have any questions about the open heart surgery. Joan states, "I am not sure I understand what the cardiopulmonary bypass machine does." What is the best response by the nurse?

"It is a machine that takes over the roles of the lungs and heart during Timmy's surgery." Special cannulas are placed in the venous side of the heart so that venous blood is shunted to the bypass machine where it receives oxygen before being sent back to the body via the aorta.

Joan asks the nurse, "Why did this happen to my baby? What did I do wrong? I should not have continued to work up until the day he was born." What is the best response by the nurse?

"It is not known what causes an infant to be born with a VSD, but a working mother is not a risk factor." Although the exact reason for a VSD is unknown, a family history of congenital heart defects and/or an exposure to a viral infection, drugs, or alcohol during pregnancy are known risk factors.

The nurse continues Timmy's admission assessment and obtains subjective data from Timmy's parents concerning his normal routine for feeding, bathing, and playing. Which statement by Joan supports Timmy's diagnosis of CHF?

"Timmy never seems to get full even when I breastfeed him for a long time." One of the earliest signs of CHF in an infant is difficulty eating. Feedings take longer, and less is consumed while more energy is expended. The infant may appear hungry and irritable soon after a feeding.

The nurse is at the nursing station when a man who identifies himself as Joan and Thomas' priest asks, "How is Timmy Owens doing? What is his room number?" How should the nurse respond?

"Timmy's room number is 410. I think Mr. Owens is in the room. I'll be happy to walk down there with you." Based on HIPAA guidelines, the correct response is to answer only the second part of the question and provide the priest with Timmy's room number. It would be a breach of the HIPAA guidelines for the nurse to divulge information about a client's condition. In addition, many hospitals have specific infant security procedures to prevent abduction. Offering to walk the visitor to the room enhances those security procedures.

Timmy has been improving daily and is due to be discharged. The nurse is completing the discharge teaching. Which statement by Joan indicates that the teaching has been effective?

"We must resume Timmy's regular meal, sleep, and play times as soon as we get home." Joan and Thomas should resume a normal schedule as soon as possible.

Which statement by Joan indicates that the teaching has been effective?

"We must resume Timmy's regular meal, sleep, and play times as soon as we get home." Thomas should resume a normal schedule as soon as possible. "Pat the incision dry, but do not rub it until it is completely healed." Rubbing the incision may cause the wound to gape open or become irritated.

Thomas tells the nurse that his mother has suggested giving Timmy some herbs that she grows in her garden. Thomas doesn't want to make his mother mad, but he does not want Timmy to be given anything that will hurt him. How should the nurse respond when addressing this alternative therapy?

"You should consult with Timmy's doctor before allowing him to get any of the herbs." Timmy should not be given anything, including herbs, before consulting with his doctor.

Joan tells the nurse that Timmy is often irritable and seems hungry all the time. Joan and Thomas are concerned that Timmy is losing weight because he gets so exhausted when feeding that he does not eat very much. The cardiologist requests that Joan stop breastfeeding and start bottle feeding. The nurse discusses feeding issues and techniques with Joan and Thomas. Thomas asks, "Why do we need to use a soft nipple with a large hole to feed Timmy?" Which response is most important for the nurse to educate the parents about feeding?

"Your son will be able to suck more easily and will not be so tired from feeding." An enlarged nipple minimizes the level of energy required to suck the milk at a rate of flow the baby can swallow comfortably.

The nurse is updating Timmy's plan of care. Which prescription for care should the nurse question as a transcription error on the plan of care?

Administer digoxin 12.5 mg IVP twice a day. Digoxin is administered in very low doses such as 0.625 mg or 1.25 mg, even for digitalization. The prescribed dose is a major overdose. In addition, Timmy has been receiving Lanoxin elixir.

Timmy is responsive but lethargic and very irritable. Timmy's pulse oximeter reading is 90%. Which intervention should the nurse implement first?

Administer oxygen to Timmy and stay with him. Oxygen administration should improve oxygen saturation level. A pulse oximeter reading of 90% is low. A normal reading is 95% to 100%.

The nurse is discussing with Joan and Thomas the medications that Timmy will be taking at home. He will continue to take digoxin (Lanoxin) elixir and furosemide (Lasix). Which intervention should the nurse include when teaching the parents about the administration of digoxin?

Advise the parents to administer the medication about 20 to 30 minutes before the infant is fed. The medication should be administered on an empty stomach to ensure the proper absorption of the medication.

Timmy's surgery is successful, and Joan and Thomas are allowed to visit him in the intensive care unit. The nurse is completing Timmy's shift assessment. His weight is 22 lbs and his length is 28 inches. Timmy's laboratory results are: Hematocrit: 38%Hemoglobin: 7 g/dL White blood cell count: 11.5 cells/mm 3 Glucose: 90 mg/dL Which additional assessment data warrants immediate intervention by the nurse?

Apical pulse rate of 88/minute. An apical pulse of 88 is low for a 1-year-old infant. Hemoglobin 7 g/dL. This is an abnormally low hemoglobin and indicates hemorrhage. The nurse should notify the surgeon immediately. Serum potassium level 2.6 mEq/l. Normal serum potassium level in an infant is 3.5-5 mEq/l. This level reflects a potentially life-threatening complication.

When preparing Timmy's nursing care plan, the nurse identifies the priority nursing diagnosis as "decreased cardiac output." Which nursing intervention must be included in Timmy's plan of care related to this diagnosis?

Assess the infant's peripheral pulses and capillary refill time. CHF results in poor peripheral perfusion and is evidenced by decreased or absent pulses and a prolonged capillary refill time. Changes in these parameters alert the nurse to a compromise in the client's condition.

Thomas is feeds Timmy using the nipple with the enlarged hole when his son starts to choke and turn blue. He becomes limp in Thomas's arms. Thomas yells for the nurse who hears his cries and rushes to the room. Which intervention should the nurse implement first?

Attempt to stimulate Timmy's breathing by rubbing the sole of his foot. The nurse may need to start cardiopulmonary resuscitation, but the first intervention is to determine if the child is unresponsive.

Joan begins to cry and says, "I want Timmy to be able to have an easier time eating, but I think breast milk is best for him. It is more easily digested and contains immune properties that he needs. Isn't there anything you can do?" As a client and family advocate, the nurse decides to explore Joan's request further since Timmy is not due to eat for 3 hours. Which member of the perinatal care team will best be able to assist the nurse?

Certified Lactation Consultant (CLC). The certified lactation consultant (CLC) has formal training and education that enables him/her to work with mothers and babies to facilitate breastfeeding.

The nurse understands that a child is experiencing heart failure when which symptoms are found?

Cool extremities. The client will have cool extremities due to the heart's inability to pump effectively. Peripheral edema. Right-sided heart failure is indicated with edema to the body. Nasal Flaring. There will be inadequate oxygenation of the blood.

The nurse is discussing all the care that will be required when Timmy is discharged home. Joan and Thomas appear overwhelmed and scared to take Timmy home. Both Thomas and Joan work outside the home, but Joan plans to quit work to care for Timmy. How should the nurse respond to this situation?

Discuss Thomas and Joan attending a support group for parents of children with congenital heart problems. Parents of children with a chronic disease may benefit from the opportunity to meet and talk with other parents whose children suffer a similar disease. The goal is to help the family manage the stress of the child's heart condition in a way that strengthens the child's development and stabilizes the family unit.

Timmy's parents are concerned that Timmy may be in pain. He has prescriptions for a continuous IV analgesic infusion and a PRN pain medication bolus. Which intervention should the nurse implement to address their concern about Timmy's postoperative pain?

Explain that a continuous IV infusion of pain medication is being given to Timmy and will provide a consistent level of pain relief. Control of pain is accomplished by a continuous IV infusion of an opiate analgesic in the immediate postoperative period. If the continuous infusion is not adequate, additional pain medication is available through a PRN bolus.

The pediatric cardiologist schedules a cardiac catheterization for the next day. The nurse prepares the family and the client for the procedure by answering questions that the family is asking. What should the nurse include when teaching Timmy's parents about post-procedure care?

Explain that they will need to hold Timmy in the prone position after the procedure. Timmy's leg that will be used as the femoral artery insertion site must be kept straight. The infant is placed prone in the lap to help keep the leg straight and to prevent hematoma formation and subsequent hemorrhage.

The nurse further educates the parents about the digoxin medication and instructs how to administer the medication. Which statement by the parents demonstrates an understanding of the instructions?

I will give my child the medication at the scheduled times. The medication should always be verified and given at the appropriate times to maintain therapeutic blood levels.

Prior to discharge, Timmy's parents must learn cardiopulmonary resuscitation (CPR) for infants. The American Heart Association's CPR technique is being taught to Thomas and Joan. Which statements by Thomas indicates that the CPR teaching has been effective?

I will perform 30 chest compressions to 2 breaths, at the rate of 100 compressions per minute. This is the correct ratio of compressions to breaths for an infant when CPR is performed by a trained individual. I will perform chest compressions prior to rescue breathing. Beginning CPR with compressions leads to a shorter delay to the first compression.

Since Timmy is receiving digoxin (Lanoxin) elixir, the nurse explains to the parents that Timmy will need to have his blood drawn every 6 months while taking the medication. Which information should the nurse include when discussing this routine laboratory test?

Instruct the parents to give a regular dose of medication at least 6 hours prior to the test. A falsely elevated level will be obtained if there is not a minimum of 6 hours between the last dose of digoxin and the venipuncture or heel stick.

Timmy is stabilized, but the nurse recognizes that he remains a high risk for fluid and electrolyte imbalance. Which intervention is important to include in Timmy's plan of care to address this concern in the immediate postoperative period?

Monitor the infant's glucose level. Glucose, a critical factor in maintaining cardiac contractility, is impacted by shifts in fluids and electrolytes.

As the nurse obtains informed consent for Timmy's cardiac catheterization, Thomas says, "I am still not exactly sure why the doctor has to do the test." Which action should the nurse implement?

Notify the cardiologist and do not allow Thomas to sign the permit. It is the responsibility of the HCP to explain any proposed procedure. The nurse should ensure that the client has an understanding of the procedure, the risks, and the advantages before witnessing the client (in this case, the minor's parent) sign the permit.

Which intervention should the nurse implement prior to administering the first dose of digoxin (Lanoxin) to Timmy?

Obtain Timmy's apical pulse to determine if it is within the guidelines of the written prescription. It is important to first check the prescription for a withholding pulse rate because the drug is not generally given if the apical pulse is below 90 to 110 beats/min in infants and young children. It is also important to remember the norms for different age groups.

When Timmy is 1 year old, he is readmitted to the pediatric cardiac unit and scheduled for open heart surgery to repair the ventricular septal defect. Joan and Thomas are at Timmy's bedside and appear very frightened about the upcoming surgery. Which preoperative intervention has priority at this time?

Offer verbal and written information about Timmy's surgery. Priority should be given to ensure that Timmy's parents have a good understanding of the surgical procedure to repair his heart.

The nurse assesses Timmy's developmental milestones in order to provide anticipatory guidelines in this area. Which activity should the nurse include when discussing activities appropriate for a 4-month-old's growth and development?

Read brightly colored books to Timmy. This would be an appropriate activity for a 4-month-old.

As part of the assessment, the CLC recommends that the nurse evaluate the effort needed to both breastfeed using a supplemental feeding device and bottle feed using the nipple with the enlarged hole. Which measurement will be most useful to evaluate Timmy's response to each feeding technique?

SaO2 changes during feeding. The SaO2 is measured via a pulse oximeter. As the effort of feeding becomes more stressful and the infant tires, a decrease in the SaO2 level will occur. Because it is a non-invasive, non-painful procedure, the infant is less likely to cry, which can confound the data.

The nurse is caring for four clients on the pediatric unit, including Timmy. Timmy is sleeping in the crib, and Joan is sitting in the room. Which of Timmy's nursing tasks would be appropriate to delegate to an unlicensed assistive personnel (UAP)?

Sit with Timmy while Joan takes a shower. A UAP can sit in the room and watch an infant while the mother takes a shower.

The nurse walks into Timmy's room to complete the shift assessment and finds him sleeping soundly in his crib and Joan crying quietly and staring out the window. Which action by the nurse is most therapeutic?

Stand by Joan and say, "I can see you are upset. Would you like to talk?" This action acknowledges the mother's crying and provides the opportunity for a therapeutic conversation. A congenital heart defect can be an unknown and frightening thing for a parent. Allowing the mother to share her feelings is the most therapeutic action the nurse can provide.

Timmy is admitted to the pediatric unit for treatment of CHF and is to be seen by a pediatric cardiologist for further cardiac assessment. The nurse interviews Joan and Thomas and completes Timmy's admission assessment. Which clinical manifestations would the nurse expect to assess in an infant diagnosed with ventricular septal defect (VSD)?

Tachypnea and grunting with intercostal and subcostal retractions. These manifestations are due to the increased workload of the heart and fluid buildup in the lungs.

Timmy's SaO2 level drops to 90% when breastfed using a supplemental feeding device and when using the nipple with the enlarged hole. Flow-by oxygen increases the SaO2 to 95%. Timmy appears to have more choking episodes with the nipple. The nurse, lactation consultant, and Timmy's parents discuss feeding options again. They decide that Joan will pump breastmilk before each feeding, and breastmilk fortifier will be added to increase Timmy's caloric intake. Joan recognizes that pumping will also allow the milk to "let-down" so Timmy will not have to expend extra sucking effort to start the milk flow. Joan will use the supplemental feeder as she breastfeeds. If Joan is unavailable, Thomas or the nurse can feed Timmy fortified breastmilk using the bottle with the enlarged hole in the nipple.

The cardiologist confirms that Timmy has ventricular septal defect (VSD) and is experiencing an acute exacerbation of CHF, which often occurs with untreated VSD. The cardiologist prescribes the cardiac glycoside digoxin elixir (Lanoxin) and the loop diuretic furosemide (Lasix) for Timmy.

Timmy is stabilized. His oxygen saturation level is 96% on room air. He tolerates his next feeding without complications. The next day the nurse is assessing Timmy's growth and development. Joan and Thomas are loving parents, and they are very interested in the care Timmy is receiving. Joan asks the nurse, "Is Timmy growing all right?" The nurse responds that Timmy seems to be right on target for a 4-month-old. Which data supports the nurse's response?

Timmy plays with his feet and puts them in his mouth. Normal gross motor movement includes playing with the feet, beginning to use legs for weight bearing, and turning from the abdomen to the back.

The nurse uses Erikson's stages of growth and development in addressing Timmy's needs. According to Erikson, which state is normal for an infant this age?

Trust vs. Mistrust. Because infants must depend on others for food, warmth, and affection, they must be able to trust their caregivers to fulfill these basic needs. If their needs are adequately met, they will learn to trust others and their environment.