SAUNDER CV PED

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1. Prone position 2. Knee-chest position 3. High Fowler's position 4. Reverse Trendelenburg's position

Knee-chest position

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1. Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the health care provider.

Withhold the medication and notify the health care provider. The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore, the remaining options are incorrect

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher than normal body weight

Bluish discoloration of the skin

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

Conjunctival hyperemia

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure?' 1. Paleness of the skin 2. Strong sucking reflex 3. Diaphoresis during feeding 4. Slow and shallow breathing

Diaphoresis during feeding

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 3. Presence of Reed-Sternberg cell 4. Decreased erythrocyte sedimentation rate 5. Presence of group A beta-hemolytic strep

Elevated C-reactive protein Elevated antistreptolysin O titer Presence of group A beta-hemolytic strep

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1. Elevated antistreptolysin O titer 2. Decreased erythrocyte sedimentation rate 3. Negative result on antinuclear antibody assay 4. Negative result on C-reactive protein determination

Elevated antistreptolysin O titer

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1. Prevents blue (tet) spells 2. Maintains adequate cardiac output 3. Maintains an adequate hormonal level 4. Maintains the position of the great arteries

Maintains adequate cardiac output

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the figure (circled area) to determine the condition. 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

Patent ductus arteriosus

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse? 1. Notify the nursing supervisor. 2. Contact the respiratory therapist. 3. Place the infant in a prone position. 4. Place the infant in a knee-chest position.

Place the infant in a knee-chest position.

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Check the blood pressure and then administer the medication. 4. Check the respiratory rate and then administer the medication.

Withhold the medication

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"

"Did the child have a sore throat or fever within the last 2 months?

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

"If my child vomits after medication administration, I will repeat the dose."

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching? 1. "Quiet activities are allowed." 2. "The child should play inside for now." 3. "Visitors are not allowed for 1 month." 4. "The regular schedule for naps is resumed."

"Visitors are not allowed for 1 month."

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1. Anxiety 2. A temper tantrum 3. A hypercyanotic episode 4. The need for immediate health care provider notification

A hypercyanotic episode

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb (0.5 kg) in 1 day

A weight gain of 1 lb (0.5 kg) in 1 day

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer

Anti-streptolysin O titer

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1. Absence of C-reactive protein 2. Presence of Reed-Sternberg cells 3. Decreased antistreptolysin O titer 4. Elevated erythrocyte sedimentation rate

Elevated erythrocyte sedimentation rate

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

Tachycardia

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

Weighing the diapers

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing

When drawing blood for electrolyte level testing

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the health care provider.

Administer the medication

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child? 1. "Has the child been vomiting?" 2. "Has the child had any diarrhea?" 3. "Does the child complain of chest pain and numbness in the right arm?" 4. "Has the child complained of a sore throat within the past few months?"

"Has the child complained of a sore throat within the past few months?"

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

"I can apply lotion or powder to the incision if it is itchy."

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1. "The child may return to school in 1 week." 2. "The child will not be able to return to school during this academic year." 3. "The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."

"The child may return to school in 3 weeks but needs to go half-days for the first few days."

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia? 1. Tachypnea 2. Tachycardia 3. Sucking on the fingers 4. Clubbing of the fingers

Clubbing of the fingers

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate? 1. Administer acetaminophen for temperature elevation. 2. Administer the aspirin if the child's temperature is elevated. 3. Administer the aspirin if the child experiences any joint pain. 4. Consult with the health care provider to verify the prescription.

Consult with the health care provider to verify the prescription

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

Exercise intolerance

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition? 1. Bleeding 2. Heart failure 3. Failure to thrive 4. Decreased tolerance to stimulation

Heart failure