Chapter 23: Cardiovascular Alteration

1. True or False: Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right and left atria, which are the lower chambers of the heart. True False

False

The nurse discovers a heart murmur in an infant 1 hour after birth. What does the nurse know about when fetal shunts close in the neonate? a. When the umbilical cord is cut b. Within several days of birth c. Within a month after birth d. By the end of the first year of life

ANS: B In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. With the neonate's first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation.

Which statement best describes patent ductus arteriosus? a. Patent ductus arteriosus involves a defect that results in a right-to-left shunting of blood in the heart. b. Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. c. Patent ductus arteriosus is a stenotic lesion that must be surgically corrected at birth. d. Patent ductus arteriosus causes an abnormal opening between the four chambers of the heart.

ANS: B Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. Patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves.

An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves a. weight control and diet. b. treating the underlying disease. c. administration of digoxin. d. administration of beta-adrenergic receptor blockers.

ANS: B Identification and treatment of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are non-pharmacologic treatments for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. Beta-adrenergic receptor blockers may be indicated in the treatment of secondary hypertension, but the main focus is on identifying and treating the underlying cause.

A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding of primary hypertension? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.

ANS: C Primary hypertension in children may be treated with weight reduction and exercise programs. Primary hypertension is usually treated with weight reduction and exercise. If ineffective, pharmacologic intervention may be needed. An exercise program in conjunction with weight reduction can be effective in managing primary hypertension in children.

What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities

ANS: D The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation.

The nurse is planning care for infants and children with congestive heart failure. Nursing care is correct if the nurse takes which approach? A. Forcing fluids appropriate for the patient's age B. Monitoring respirations during active periods C. Giving larger feedings less often to conserve energy D. Organizing activities to allow for uninterrupted sleep

D. Organizing activities to allow for uninterrupted sleep The child needs to be well rested before feeding. The child's needs should be met as quickly as possible to minimize crying. The nurse must organize care to facilitate a decrease in the child's energy expenditure which is known as clustering care. The child who has congestive heart failure has an excess of fluid. Monitoring of vital signs is appropriate, but minimizing energy expenditure is a priority. The child often cannot tolerate larger feedings.

The nurse is caring for a child whose cardiac condition is classified as a mixed-blood cardiac defect. What diagnosis would the nurse expect to see on the patient's chart? A. Pulmonic stenosis B. Atrial septal defect C. Patent ductus arteriosus D. Transposition of the great arteries

D. Transposition of the great arteries Transposition of the great arteries allows the mixing of blood in the heart. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect is classified as a defect with increased pulmonary blood flow. Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow.

2. What other congenital heart defect is most commonly present in truncus arteriosus? A. Atrial septal defect B. Pulmonary stenosis C. Tetralogy of Fallot D. Ventricular septal defect

D. Ventricular septal defect The answer is D. A ventricular septal defect (VSD) is commonly present in this CHD. The VSD will be near the truncus arteriosus and it will allow blood to mix in the right and left ventricles and enter the truncus artery. It is very uncommon for one not to be present.

8. True or False: Atrial septal defects can lead to a decrease in lung blood flow. True False

False

3. TRUE or FALSE: A small muscular ventricular septal defect has a high probability of self-closure, and these types of VSDs are found in the lower portion of the ventricular septum. True False

True

5. True or False: In a normal heart without any type of congenital heart defect, the pulmonary vein carries oxygenated blood away from the lungs to the left side of the heart. True False

True

A nurse caring for a child post cardiac catheterization assesses that the distal pulse of the catheter site is weaker and capillary refill less than 3 seconds. What is the most appropriate nursing action? A. Elevate the affected extremity. B. Notify the physician of the observation. C. Apply warm compresses to insertion site. D. Record the assessment finding.

D. Record the assessment finding. The pulse distal to the catheter insertion site may be weaker for the first few hours after catheterization and should gradually increase in strength. The capillary refill is normal. Elevation is not necessary; the extremity is kept straight. Because a weaker pulse is an expected finding and the capillary refill is within normal range, the nurse should document this and continue to monitor. The insertion site is kept dry.

3. A newborn has severe coarctation of the aorta. What signs and symptoms would you expect to find in this patient? Select all that apply: A. Very strong bounding pulses in the upper extremities B. Cool legs and feet C. Machine-like murmur only on systole D. Tet spells with activity E. Severe cyanosis F. Absent/diminished femoral pulses

A. Very strong bounding pulses in the upper extremities B. Cool legs and feet F. Absent/diminished femoral pulses

Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.

ANS: D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. The other interventions are appropriate.

6. Select the structure below that allows blood to flow from the right to left atrium in utero and that should close after birth: A. Ductus Arteriosus B. Formen Ovale C. Ductus Venosus D. Ligamentum teres

B. Formen Ovale

Which heart defect and hemodynamic change pairing is correct ? A. Aortic Stenosis and obstruction to blood flow out of the heart. B. Ventricular Septal Defect and decreased pulmonary blood flow C. Tricuspid atria and increased pulmonary blood flow. D. Atrioventricular canal and mixed blood flow, in which matured and denatured blood mix within the heart or great arteries.

A. Aortic Stenosis and obstruction to blood flow out of the heart.

A child is being watched for possible heart failure. Which sign would alert the nurse that congestive heart failure could be developing? A. Tachypnea B. Bradycardia C. Inability to sweat D. Increased urine output

A. Tachypnea Tachypnea is one of the early signs that should be identified. Tachycardia at rest, dyspnea, retractions, and activity intolerance are other physical signs and symptoms. Tachycardia, not bradycardia, is one of the symptoms suggestive of congestive heart failure. The child may be diaphoretic. Urine output usually will be decreased.

A 3-week-old neonate has been admitted to the hospital because of an inability to feed well and not growing as expected. What actions should the nurse implement when caring for this infant with suspected heart failure? Select all that apply. A. Allow extra time to feed the infant. B. Hold the infant securely in a supine position during feeding. C. Allow 45 minutes for each feeding to provide the ordered amount of formula. D. Watch for diaphoresis or tachypnea while feeding the infant. E. Encourage the mother to breastfeed, but allow 30 minutes for the total feeding. F. Watch for signs of hunger and irritability soon after the feeding is finished.

A, D, E, F Allowing extra time to feed the infant should help the nurse provide the relaxed environment that this infant needs. Knowing that 30 minutes should be allocated for each feeding helps the nurse with time management. If diaphoresis or tachypnea is seen while the infant is feeding, then the infant may need a feeding tube to conserve energy. Encourage the mother to breastfeed, but allow 30 minutes for the total feeding. Signs of hunger and irritability soon after the feeding is finished may indicate that the feeding did not fill up the infant so that comfort and fullness would be felt. Holding the infant securely in an upright position may provide less stomach compression and improve respiratory effort during the feeding. Allow 30 minutes for each feeding to provide the ordered amount of formula

6. You're teaching a class to a group of parents about congenital heart defects. During the class discussion, you ask the group to describe the surgical repair for truncus arteriosus. Select all the TRUE statements by the group members about this surgical repair: A. "During the surgery the pulmonary arteries are separated from the truncus arteriosus and connected to the right ventricle using a valved conduit." B. "This surgery is done within the first 2-3 months of life." C. "Some patients may need another surgical repair later on because of narrowing of the conduit that may occur or they may outgrow it." D. "During the surgery the aorta is separated from the truncus arteriosus and connected to the left ventricle using a valved conduit."

A. "During the surgery the pulmonary arteries are separated from the truncus arteriosus and connected to the right ventricle using a valved conduit." C. "Some patients may need another surgical repair later on because of narrowing of the conduit that may occur or they may outgrow it."

7. A family member, who is caring for a 2-year-old with Tetralogy of Fallot, asks you why the child will periodically squat when playing with other children. Your response is: A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." B. "Squatting helps to decrease systemic vascular resistance, which will decrease the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels." C. "Squatting helps to decrease systemic vascular resistance, which will increase the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels." D. "Squatting helps to normalize systemic vascular resistance, which will increase the left to right shunt that is occurring in the ventricles and this helps increase oxygen levels."

A. "Squatting helps to increase systemic vascular resistance, which will decrease the right to left shunt that is occurring in the ventricles and this helps increase oxygen levels."

3. As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply: A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."

A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." D. "Many patients with this condition will experience clubbing of the nails." The answers are A, B, and D. Option C is wrong because this condition can be treated with both palliative surgery (used to help alleviate symptoms until the child is old enough for complete repair) and complete repair. All the other options are correct.

1. Select all the true statements about the aorta: A. "The ascending aorta branches off to supply the coronary arteries of the heart." B. "It's the third largest artery in the body." C. "The aorta comes off the right ventricle and supplies oxygenated blood to the body." D. "The aortic arch branches off to supply the head, neck, and upper extremities."

A. "The ascending aorta branches off to supply the coronary arteries of the heart." D. "The aortic arch branches off to supply the head, neck, and upper extremities." The answers are A and D. These statements are true about the aorta. Option B is wrong because the aorta is the LARGEST artery in the body (not the third largest). Option C is wrong because the aorta comes off the LEFT (not right) ventricle.

2. As the nurse you know which statements below are correct about the ductus arteriosus? Select all that apply:* A. "The ductus arteriosus is a structure that should be present in all babies in utero." B. "The ductus arteriosus normally closes about 3 days after birth or sooner." C. "The purpose of the ductus arteriosus is to help carry blood that is entering the left side of the heart to the rest of the body, hence bypassing the lungs." D. "The ductus arteriosus connects the aorta to the pulmonary vein."

A. "The ductus arteriosus is a structure that should be present in all babies in utero." B. "The ductus arteriosus normally closes about 3 days after birth or sooner." The answers are A and B. These are correct statements about the ductus arteriosus. Option A is correct because every newborn should have this structure, but it will close shortly after birth. Option C is wrong because the purpose of this structure is to help carry blood that is entering the RIGHT side (not left) of the heart to the rest of the body, hence bypassing the lungs. Option D is wrong because this structure connects the aorta to the pulmonary ARTERY (not vein).

7. After admitting a child with an atrial septal defect, you start developing a nursing care plan. What nursing diagnoses can you include in the patient's plan of care based on the complications that arise from this condition? Select all that apply: A. Activity Intolerance B. Risk for Infection C. Decrease Cardiac Output D. Excess Fluid Volume E. Risk for Aspiration

A. Activity Intolerance B. Risk for Infection C. Decrease Cardiac Output D. Excess Fluid Volume The answers are A, B, C, and D. Patients who are hospitalized with an ASD will be having complications that arise from the left to right shunt of blood flow in the heart, which can lead to heart failure and pulmonary hypertension. In heart failure, there is decreased cardiac output, which will lead to activity intolerance and excess fluid volume. Furthermore, pulmonary hypertension is presenting and this will cause the lungs to become congested with fluid. Many patients with a large ASD will have frequent lung infections from the congestion in the lungs. So, the patient is at risk for infection.

You are working with a new graduate on the pediatric unit and your patient is returning from cardiac catheterization lab. You feel the graduate understands the importance nursing interventions when she says which of the following ? Select all that apply A. Check pulses especially bellow the catheterization site, for equality ad symmetry. B. Check vitals, which maybe taken as frequently as every 30 -45 minutes, which special emphasis on the heart rate, which is counted for 1 full minutes for evidence of dysthymia or bradycardia. C. Special attention needs to be given to the BP, especially for hypertension, which may indicate hemorrhage or bleeding from the catheterization site. D. Check the dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area. E. Allow the child to ambulate because this will prevent skin breakdown from lying so long in one place.

A. Check pulses especially bellow the catheterization site, for equality ad symmetry. D. Check the dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area.

6. As the nurse you know that some patients who have coarctation of the aorta will develop collateral circulation of the arteries due to the abnormality on the aorta. Which option below indicates a patient is experiencing collateral circulation? A. Chest x-ray that demonstrates notching on the ribs B. A harsh diastolic murmur on inspiration at the 2nd intercostal border C. Ejection fraction of 12% on an echocardiogram D. Chest x-ray that demonstrates cardiomegaly

A. Chest x-ray that demonstrates notching on the ribs The answer is A. Notching of the ribs is due to collateral circulation in CoA. The body creates extra circulation to bypass the narrowing, which will be seen on the ribs and cause them to have a notched out appearance on a chest x-ray.

5. A 1-day-old infant is ordered an echocardiogram due to abnormal signs and symptoms related to a congenital heart defect. The echo confirms that truncus arteriosus is present. What signs and symptoms may present in this congenital heart defect? Select all that apply: A. Cyanosis B. Machinery-like murmur C. Poor feeding D. Inability to gain weight E. Hypercyanotic spells F. Clubbing of fingers

A. Cyanosis C. Poor feeding D. Inability to gain weight The answers are A, C, and D. Deoxygenated blood is going to the body, while more blood is shifting to pulmonary circulation via a shared artery. This leads to cyanosis (bluish body at birth) and dyspnea. Heart failure and pulmonary hypertension occur within the first weeks of life. The baby can experience poor feeding and poor weight gain, low cardiac output, activity intolerance, sweating that is cold and calmly, nutrition issues, crackles in lungs etc. A heart murmur from the blood flowing through the truncus arteriosus can create a turbulence leading to an ejection systolic murmur heard at the left sternal border. A machinery-like murmur is present in patent ductus arteriosus, and hypercyanotic spells are present in tetralogy of fallot (also called tet spells).

7. You're providing education to the parents of a child who has a patent ductus arteriosus. The parents want to know the complications of this condition. In your education, you will include which of the following complications of PDA? Select all that apply:* A. Heart failure B. Pulmonary hypertension C. Recurrent lung infections D. Clubbing of the fingernails E. Endocarditis F. Pulmonary stenosis

A. Heart failure B. Pulmonary hypertension C. Recurrent lung infections E. Endocarditis The answers are A, B, C, and E. These are complications that can occur with PDA. Clubbing of the nails can be seen in tetralogy of fallot.

7. A 4-month-old is scheduled to take Digoxin for treatment of a ventricular septal defect. The patient's apical pulse is 89 beats per minute. As the nurse you will? Select all that apply: A. Hold the dose B. Recheck the pulse via the brachial artery C. Administer the dose as scheduled D. Notify the physician

A. Hold the dose D. Notify the physician The answer is A and D. Before giving Digoxin, the apical pulse should be checked for 1 complete minute. The infant's heart rate is too low in this scenario. Guidelines say to hold Digoxin in infants if the apical pulse rate is less than 90-110 beats per minute, children less than 70 bpm, or adults less than 60 bpm. The nurse would HOLD the dose and NOTIFY the physician for further orders. The physician needs to be informed of this and may want to investigate if the patient is experiencing toxicity of this medication.

You are working with a family with a child who has a congenital heart defect. Future surgery is planned, and you are teaching the parent how to reduce cardiac demands. The parent needs more teaching when she says which of the following ? A. I will wake my child for feeding every 2 hours so he can get enough calories to gain weight B. When I give the digoxin, I will listen to the pulse for 1 full minutes. C. I should protect my child from people who has respiratory infection D. I will count the number of wet diapers to be sure my child is not getting too much or too little fluids.

A. I will wake my child for feeding every 2 hours so he can get enough calories to gain weight

As part of the treatment for congestive heart failure, a child is taking the diuretic furosemide (Lasix). As part of the discharge teaching plan, what should the nurse explain as the function of furosemide (Lasix)? A. It is a diuretic, which means that it eliminates extra fluid from the body. B. It is a beta blocker, which decreases the child's blood pressure. C. It is a form of digitalis that regulates the heart rate and rhythm. D. It is an ACE inhibitor, which regulates the amount of fluid that goes through the kidney.

A. It is a diuretic, which means that it eliminates extra fluid from the body. Furosemide (Lasix) is a diuretic used to eliminate excess water and salt to prevent re-accumulation of the fluid.

6. After speaking with the mother of the infant in the previous question, who may have a ventricular septal defect, you auscultate heart sounds. If a ventricular septal defect was present, you may hear a harsh murmur that is _______________________. A. Located at the lower left sternal border and starts at S1 and extends into S2. B. Located at the upper left sternal border and is continuous during systole. C. Located at the lower left sternal border and is continuous machine-like. D. Located at the upper left sternal border and is only heard during diastole.

A. Located at the lower left sternal border and starts at S1 and extends into S2. The answer is A. The size of the VSD depends on the how loud the murmur will be, but it will be heard at the LOWER LEFT sternal border and is considered a holosystolic or pansystolic murmur. This means it will start at S1 and extend into S2.

3. An echocardiogram shows that your patient has an atrial septal defect located at the bottom of the septum near the tricuspid and mitral valves. As the nurse you know this is what type of atrial septal defect (ASD)? A. Ostium Primum B. Ostium Secundum C. Sinus Venosus D. Coronary Sinus

A. Ostium Primum The answer is A. An ostium primum is an atrial septal defect located at the bottom of the septum near the tricuspid and mitral valves (atrioventricular valves).

What is the nurse's first action when planning to teach the parents of an infant with a CHD? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.

ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness.

Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril b. Furosemide c. Spironolactone d. Chlorothiazide

ANS: A Capoten is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide is a diuretic.

A beneficial effect of administering digoxin is that it a. decreases edema. b. decreases cardiac output. c. increases heart size. d. increases venous pressure.

ANS: A Digoxin improves cardiac output, which will lead to decreased edema although it is not a diuretic. It does not increase heart size or increase venous pressure.

What intervention should be included in the plan of care for an infant with the nursing diagnosis of excess fluid volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin as ordered by the physician.

ANS: A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Digoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia b. Infection c. Dehydration d. Anemia

ANS: A Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection, dehydration, and anemia are not clinical consequences of cyanosis.

In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner syndrome

ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner syndrome, have a higher incidence of CHD. A family history is not a risk factor.

Before giving a dose of digoxin the nurse checked an infant's apical heart rate and it was 114 beats/minute. What should the nurse do next? a. Administer the dose as ordered. b. Hold the medication until the next dose. c. Wait and recheck the apical heart rate in 30 minutes. d. Notify the physician about the infant's heart rate.

ANS: A The infant's heart rate is above the lower limit for which the medication is held (100 beats/minute in an infant). The dose can be given. No other action is needed.

What should the nurse include in discharge teaching as the highest priority for the child with a cardiac dysrhythmia? a. CPR instructions b. Repeating digoxin if the child vomits c. Resting if dizziness occurs d. Checking the child's pulse after digoxin administration

ANS: A This could potentially be life-saving for the child. The parents and significant others in the child's life should have CPR training. The digoxin dose is not repeated if the child vomits. Dizziness is a symptom the child should be taught to report to adults so that the physician can be notified. It is not the priority intervention. The child's pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician.

Which CHD results in increased pulmonary blood flow? a. Ventricular septal defect b. Coarctation of the aorta c. Tetralogy of Fallot d. Pulmonary stenosis

ANS: A Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. The defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.

A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child's parents? (Select all that apply.) a. Replace whole milk with 1% milk. b. Increase servings of red meat. c. Increase servings of fish. d. Avoid excessive intake of fruit juices. e. Limit servings of whole grain.

ANS: A, C, D A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats.

Which strategy is appropriate when feeding the infant with congestive heart failure? a. Continue the feeding until a sufficient amount of formula is taken. b. Limit feeding time to no more than 30 minutes. c. Always bottle feed every 4 hours. d. Feed larger volumes of concentrated formula less frequently.

ANS: B The infant with congestive heart failure may tire easily, so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. The infant is fed smaller volumes of concentrated formula every 3 hours.

The primary nursing intervention to prevent bacterial endocarditis is which of the following? a. Institute measures to prevent dental procedures. b. Counsel parents of high-risk children about prophylactic antibiotics. c. Observe children for complications, such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.

ANS: B The objective of nursing care is to counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Observing children for complications should be done, but maintaining good oral health and prophylactic antibiotics is important. Restricted mobility may or may not be necessary.

Which statement suggests that a parent understands how to correctly administer digoxin? a. "I measure the amount I am supposed to give with a teaspoon." b. "I put the medicine in the baby's bottle." c. "When she spits up right after I give the medicine, I give her another dose." d. "I give the medicine at 8 in the morning and evening every day."

ANS: D For maximum effectiveness, the medication should be given at the same time every day. The maintenance dose is given in two divided doses daily. To ensure the correct dosage, the medication should be measured with a syringe. To prevent toxicity, the parent should not repeat the dose without contacting the child's physician.

A child had an aortic stenosis defect surgically repaired 5 months ago. Which antibiotic prophylaxis is indicated for an upcoming tonsillectomy? a. No antibiotic prophylaxis is necessary. b. Amoxicillin is taken orally 1 hour before the procedure. c. Oral penicillin is given for 7 to 10 days before the procedure. d. Parenteral antibiotics are administered for 5 to 7 days after the procedure.

ANS: B The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. Antibiotic prophylaxis is indicated for the first 6 months after surgical repair. Antibiotic prophylaxis is not given for 7 to 10 days nor is it given parenterally.

What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. b. Alert the provider. c. Withhold oral feeding. d. Increase the oxygen rate.

ANS: B These are signs of early congestive heart failure, and the provider should be notified. Rechecking the blood pressure is not necessary. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the provider is the priority nursing action.

The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. What action by the nurse is most appropriate? a. Educate parents on daily low-dose aspirin regime. b. Prepare to administer indomethacin. c. Administer next dose of enalapril early. d. Position infant in the knee-chest position.

ANS: B This murmur is characteristic of a patent ductus arteriosus, which is treated medically with indomethacin. A daily low-dose aspirin is indicated for 6 months following repair of an ASD. ACE inhibitors (enalapril) are used to reduce afterload in a VSD. The knee-chest position is helpful in tet spells that occur in tetralogy of Fallot.

The nurse working in the newborn nursery notices an infant who is having circumoral cyanosis. Which CHD does the nurse suspect the child may have? (Select all that apply.) a. Patent ductus arteriosus (PDA) b. Tetralogy of Fallot c. Pulmonary atresia d. Transposition of the great arteries e. Ventricular septal defect

ANS: B, C, D Tetralogy of Fallot is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Pulmonary atresia is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Transposition of the great arteries is a cyanotic lesion with increased pulmonary blood flow. PDA is failure of the fetal shunt between the aorta and the pulmonary artery to close. PDA is not classified as a cyanotic heart disease. Prostaglandin E1 is often given to maintain ductal patency in children with cyanotic heart diseases. VSD is the most common type of cardiac defect. The VSD is a left-to-right shunting defect; however, it may be accompanied by other defects.

The nurse is admitting a child who has been diagnosed with Kawasaki disease. What is the most serious complication for which the nurse should assess in Kawasaki disease? a. Cardiac valvular disease b. Cardiomyopathy c. Coronary aneurysm d. Rheumatic fever

ANS: C Coronary artery aneurysms are seen in 20% to 25% of children with untreated Kawasaki disease. Cardiac valvular disease can occur in rheumatic fever. Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. Rheumatic fever is not a complication of Kawasaki disease.

A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session? a. Oxygen is carried to the fetus by the umbilical arteries. b. Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale. c. Pulmonary vascular resistance is high because the lungs are filled with fluid. d. Blood flows from the ductus arteriosus to the pulmonary artery.

ANS: C Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. Oxygen and nutrients are carried to the fetus by the umbilical vein. The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta.

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

ANS: C The atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. The other three diseases do not result in increased pulmonary blood flow.

When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm b. The left arm c. All four extremities d. Both arms while the child is crying

ANS: C When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease.

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if which conditions occur? (Select all that apply.) a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal

ANS: C, D, E The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7° C; new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly.

The nurse caring for a child diagnosed with acute rheumatic fever should assess the child for which of the following? a. Sore throat b. Elevated blood pressure c. Desquamation of the fingers and toes d. Tender, warm, inflamed joints

ANS: D Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of acute rheumatic fever in the first 1 to 2 weeks of the illness. The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. Hypertension is not associated with rheumatic fever. Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome.

A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic? a. Place the infant in a knee-chest position. b. Administer oxygen. c. Administer morphine sulfate. d. Calm the infant.

ANS: D Calming the crying infant is the first response. An infant with unrepaired tetralogy of Fallot who is crying and agitated may eventually lose consciousness. Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. This should be done after calming the infant. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant and depresses respirations. It may be indicated sometime after the infant has been calmed.

A common, serious complication of rheumatic fever is a. seizures. b. cardiac dysrhythmias. c. pulmonary hypertension. d. cardiac valve damage.

ANS: D Cardiac valve damage is the most significant complication of rheumatic fever. The other three are not common complications of rheumatic fever.

Nursing care for the child in congestive heart failure includes which of the following activities? a. Counting the number of saturated diapers b. Putting the infant in the Trendelenburg position c. Removing oxygen while the infant is crying d. Organizing care to provide rest periods

ANS: D Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying if needed.

For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation b. To control pain c. To decrease respirations d. To improve oxygenation

ANS: D Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation. It is not given for inflammation, pain, or to decrease respirations.

What is the most common causative agent of bacterial endocarditis? a. Staphylococcus albus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Streptococcus viridans

ANS: D S. viridans and S. aureus are the most common causative agents in bacterial (infective) endocarditis. The others are not common causative agents.

Which statement made by a parent indicates understanding of restrictions for a child after cardiac surgery? a. "My child needs to go to bed early for a few weeks." b. "My son is really looking forward to riding his bike next week." c. "I'm so glad we can attend religious services as a family this coming Sunday." d. "I am going to keep my child out of day care for 6 weeks."

ANS: D Settings where large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care and other public places such as churches. The child should resume his regular bedtime and sleep schedule after discharge. Due to fatigue, the child may initially need some naps during the day.

The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a cardiac assessment? a. Percussion b. Palpation c. Auscultation d. History and inspection

ANS: D The assessment should begin with the least threatening interventions—the history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. Percussion of the chest is usually deferred. Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. Auscultation requires touching the child and is not the initial step in a cardiac assessment.

Which information should be included in the nurse's discharge instructions for a child who underwent a cardiac catheterization earlier in the day? a. Pressure dressing is changed daily for the first week. b. The child may soak in the tub beginning tomorrow. c. Contact sports can be resumed in 2 days. d. The child can return to school on the third day after the procedure.

ANS: D The child can generally return to school on the third day after the procedure. The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. Bathing is limited to a shower, a sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure.

The nurse is caring for a child with Kawasaki disease. The child weighs 33 pounds. When initiating aspirin therapy, what dose does the nurse prepare to administer? a. 75 mg orally once a day b. 81 mg orally twice a day c. 200 mg three times a day d. 375 mg orally four times a day

ANS: D When initiating aspiring for Kawasaki disease, it is started at the anti-inflammatory dose of 80 to 100 mg/kg divided into four doses a day. This child weighs 15 kg so 100 mg 15 kg = 1500 mg. Divided into four doses is 375 mg four times a day. 75 mg once a day is the maintenance dose used for antiplatelet aggregate purposes. 81 mg a day is the adult antiplatelet aggregate dose.

5. You're providing discharge education to the parents of a child who just had surgery to repair coarctation of the aorta. What should the nurse include in the teaching about issues that can arise after surgery that must be closely monitored by a cardiologist? Select all that apply: A. Dilation of the aorta B. Restenosis of the aorta C. Hyperglycemia D. Hypertension

B. Restenosis of the aorta D. Hypertension The answers are B and D. After repair of the aorta, there is always the chance the aorta can narrow again (restenosis) and that the child continues to have hypertension that must be treated with medication. The cardiologist will need to monitor the patient for this long-term.

1. A newborn is diagnosed with truncus arteriosus. You're educating the parents about this heart defect. Which statement by the mother demonstrates she understood the education provided about this condition? A. "My baby has narrowing in the pulmonary artery, and the aorta is arising out of the right ventricle rather than the left ventricle." B. "My baby's heart shares one artery that connects the right and left ventricles." C. "The left side of my baby's heart is not fully developed." D. "The natural structure in my baby's heart, the ductus arteriosus, has failed to close after birth leading to more blood flow to the lungs."

B. "My baby's heart shares one artery that connects the right and left ventricles." The answer is B. Truncus arteriosus is a congenital heart defect where there is ONE artery along with one truncal valve that connects the right and left ventricles. This structure will function to carry blood to both the lungs and body. In a normal heart, there should be TWO separate arteries (pulmonary artery and aorta) with their own valves (instead of one truncal valve). The pulmonary artery will carry blood from the right side of the heart to the lungs, and the aorta will carry blood from the left side of the heart to the body.

2. You're caring for a child with coarctation of the aorta and educating the parents about the child's condition. Which statement by the parents demonstrates they understood the pathophysiology of this defect? A. "This condition can lead to right-sided heart failure." B. "The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta." C. "The dilation of the aorta leads to a decrease blood pressure in the arteries that are found after the site of dilation." D. "The upper and lower extremities will experience a decrease in blood flow due to the defect in the aorta."

B. "The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta." The answer is B. This is the only correct statement about CoA. Option A is wrong because this condition leads to LEFT side heart failure (not right side). Option C is wrong because this condition is due to NARROWING (not dilation) of the aorta. Option D is wrong because ONLY the lower extremities (not upper) will experience a decrease in blood flow.

1. You're caring for a 2-day-old infant with a large patent ductus arteriosus. The mother of the infant is anxious and asks you to explain her child's condition to her again. Which statement below BEST describes this condition?* A. "The vessel connecting the aorta and pulmonary vein has closed prematurely, which is leading to increased blood flow to the lungs." B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood." C. The vessel connecting the aorta and pulmonary vein has failed to close at birth, which is leading to a right-to-left shunt of blood." D. "The vessel connecting the aorta and pulmonary artery has closed prematurely, which is leading to a left-to-right shunt of blood."

B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood." The answer is B. Patent ductus arteriosus (PDA) occurs when the vessel that normally connects the aorta and pulmonary artery in utero has failed to close at birth, which leads to a left-to-right shunting of blood. This shunting of blood will increase blood flow to the lungs and can cause pulmonary hypertension and eventually heart failure (left-sided), especially if the PDA is large.

5. You're working on a unit that provides specialized cardiac care to the pediatric population. Which patient below would be the best candidate for Indomethacin from the treatment of patent ductus arteriosus?* A. A 25-year-old adult B. A premature infant C. An 8 month old child D. A 12 year old child

B. A premature infant The answer is B. A medication (NSAIDs) can be used to close the ductus arteriosus. Indomethacin is a prostaglandin inhibitor. It is used in premature babies or sometimes in very young infant's days old. It won't work for older infants, children, or adults.

The nurse is preparing to administer digoxin (Lanoxin) orally to a 9-month-old infant. The nurse checks the dose and prepares to draw up 4 mL of the drug. What are the most appropriate nursing actions? A. Mix the dose with several milliliters of juice to disguise the drug's taste. B. After checking the dosage with another nurse, hold the dose. C. Check the heart rate, and then administer the dose by placing it at the side of the mouth. D. Check the heart rate, and then give the dose by letting the infant suck it through a nipple.

B. After checking the dosage with another nurse, hold the dose. Digoxin is often prescribed in micrograms. Rarely is more than 1 mL administered to an infant. Because it is a potentially dangerous drug, administration guidelines are very precise. Pediatric medication dosages should be checked with another licensed professional before administration. Checking the heart rate and administering the dose by placing it at the back and side of the mouth are correct procedures, but the dosage is too high. Checking the heart rate and administering the dose by letting the infant suck it through a nipple are correct procedures, but the dosage is too high. The dosage is too high and should not be given. The physician must be immediately notified about the dosage error so the infant can receive the dose needed as close to the administration schedule.

7. After the birth of a newborn with severe coarctation of the aorta, the physician orders a prostaglandin infusion. As the nurse you know that this medication will have what type of therapeutic effects? Select all that apply: A. Prevent the foramen ovale from closing B. Allow a connection between the aorta and pulmonary artery C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities

B. Allow a connection between the aorta and pulmonary artery C. Decrease the workload on the left ventricle D. Increase blood flow to the lower extremities The answers are B, C, and D. If CoA is severe in a newborn, they may be started on a prostaglandin infusion to keep the ductus arteriosus open (allows a connection between the pulmonary artery and aorta), which will help decrease the work load on the left ventricle and help blood to flow to the lower extremities.

3. A newborn baby, who is diagnosed with transposition of the great arteries, is ordered by the physician to be started on an infusion of prostaglandin E (alprostadil). The purpose of this medication is to: A. Prevent the closure of the foramen ovale. B. Allow a continued connection between the aorta and pulmonary artery via the ductus arteriosus. C. Prevent the closure of the ductus venosus. D. Increase the blood flow to the pulmonary vein, which will increase oxygen levels.

B. Allow a continued connection between the aorta and pulmonary artery via the ductus arteriosus. The answer is B. Prostaglandin E (alprostadil) is an infusion that can be given to a baby with TGA. This will provide temporary relief from the TGA by keeping the ductus arteriosus open (normally this structure will close after birth). The ductus arteriosus will keep the connection between the aorta and pulmonary artery open, which will allow unoxygenated and oxygenated blood to mix and enter circulation. In TGA, oxygenated blood is not able to enter the systemic circulation, but if this structure is kept open it will allow this to occur. This infusion is only temporary until a balloon atrial septostomy or arterial switch procedure can be performed.

You are working in the pediatric clinic, and a child presents with symptoms that are suspicious of the acute phase of Kawasaki disease. Which of the following symptoms are included ? Select all that apply A. Periungual desquamation (peeling that begins under the fingertips and toes) of the hands and feet is present. B. The bulbar conjunctivae of the eyes becomes reddended with clearing around the iris. C. A temporary arthritis is evident, which may affect the larger weight-bearing joints. D. Inflammation of the pharynx and the oral mucosa develops with red, cracked lips and the chracteristic "strawberry tounge" E. Loud pan systolic murmur along with ECG changes are present.

B. The bulbar conjunctivae of the eyes becomes reddended with clearing around the iris. D. Inflammation of the pharynx and the oral mucosa develops with red, cracked lips and the chracteristic "strawberry tounge"

7. Select all the signs and symptoms of how a newborn with transposition of the great arteries may present after birth: A. Machinery-like heart murmur B. Cyanosis C. Low oxygen levels D. Bounding pulses in the upper extremities E. Increased respiratory rate F. Increased heart rate G. Knee-to-chest position

B. Cyanosis C. Low oxygen levels E. Increased respiratory rate F. Increased heart rate The answers are: B, C, E, and F. Babies with TGA will experience severe cyanosis after birth that will become worse and not resolve on its own. This is because the pulmonary and systemic circulations are not working together. Hence, the oxygenated blood never reaches the systemic circulation (it just keeps re-circulating on the left side of the heart). Therefore, the baby will have cyanosis (a bluish skin tone) until medical intervention is performed along with low oxygen levels (this is leading to the cyanosis), increased respiratory and heart rate (due to the low oxygen levels...the heart and lungs are trying to compensate by getting more oxygen to the body's organs/tissues but it is unsuccessful).

10. Prior to surgery for truncus arteriosus, what medications may be ordered to help with heart function and complications related to heart failure? Select all that apply: A. Angiotensin II receptor blockers (ARBs) B. Digoxin C. ACE Inhibitors D. Diuretics

B. Digoxin C. ACE Inhibitors D. Diuretics The answers are B, C, and D. Digoxin, ACE inhibitors, and Diuretics may be ordered to help with heart function and prevent complications associated with heart failure in an infant prior to surgery.

5. A concerned mother brings her 3-month-old to the clinic. The mother states the infant seems to be small for its age. In addition, she states the infant fatigues very easily while feeding and rarely finishes a feeding. While collecting a thorough health history, what other signs and symptoms described by the mother may indicate the child has a congenital heart defect, such as a ventricular septal defect? Select all that apply: A. Diarrhea B. Frequent treatment for lung infections C. Excessive wet diapers D. Diaphoresis when nursing E. Swelling in the hands and feet

B. Frequent treatment for lung infections D. Diaphoresis when nursing E. Swelling in the hands and feet

4. A 3-day-old infant is diagnosed with truncus arteriosus. As the nurse, you know to monitor the infant for what complications? Select all that apply: A. Tet spells B. Heart failure C. Pulmonary hypertension D. Increased cardiac output

B. Heart failure C. Pulmonary hypertension The answers are B and C. This infant has only one artery that is arising out of the right and left ventricle. Deoxygenated and oxygenated blood is mixing in the ventricles, entering the truncus arteriosus, and going to both the lungs and systemic circulation. Consequently, more blood is flowing to the lungs than the systemic circulation (the body) because resistance in lower to the lungs than the body. Hence, it is easier to pump blood to the lungs than to body (blood flow to the body requires a lot of pressure when compared to the lungs). It's important to note that the blood that is entering the body is a mixture of deoxygenated and oxygenated blood (leading to cyanosis). Now because there is more blood flow going to the lungs, this leads to damage to the arteries that feed the lungs, and this leads to pulmonary hypertension. The pulmonary hypertension increases the resistance the heart must pump against to get the blood to the lungs. Therefore, the heart becomes very weak from having to pump so hard against the resistance to the lungs, and this leads to heart failure. Many infants with a severe case of truncus arteriosus will develop heart failure within the first 7 days of life. Tet spells are found in the congenital heart defect tetralogy of fallot, and there is DECREASED cardiac output with this condition (not increased).

2. A patient is diagnosed with a large atrial septal defect. You're providing information for the patient on the complications related to this condition. What topics will you include in the patient's education? Select all that apply: A. Tet spells B. Heart failure C. Stroke D. Pulmonary Hypertension E. Rheumatic Fever

B. Heart failure C. Stroke D. Pulmonary Hypertension The answers are B, C, and D. All of these are complications of a large atrial septal defect.

You are discharging a 5 week old infant with a congenital heart defect who will be going home on digoxin. Which of the following answers by the father indicate the need for more teaching ? Select all that apply A. I know I give the drug carefully by slowly directing it to the side and back of the mouth. B. I give the medication every 12 hours and I can place it in a bit of formula so that I know the baby will take it. C. If i miss a dose, I don't give an extra dose. but I will give the next dose as ordered. D. If the baby vomits, I should give a second dose. E. IF more than two doses have been missed, I should call the doctor.

B. I give the medication every 12 hours and I can place it in a bit of formula so that I know the baby will take it. D. If the baby vomits, I should give a second dose.

9. You're developing a care plan for an infant with truncus arteriosus. When analyzing the pathophysiology for this condition, what nursing diagnosis can be included in this patient's plan of care? Select all that apply: A. Risk for increase cardiac output B. Imbalance Nutrition C. Activity intolerance D. Ineffective breathing pattern

B. Imbalance Nutrition C. Activity intolerance D. Ineffective breathing pattern The answers are B, C, and D. This patient with truncus arteriosus may experience heart failure and pulmonary hypertension along with cyanosis. Heart failure will lead to fatigue, which leads to an inability to tolerant activity (this includes feeding). The infant is at risk for poor feeding and may not be able to gain weight. In addition, breathing will be affected because a dyspnea experienced due to heart failure and cyanosis (patient is unable to get oxygenated blood to the body) leading to an ineffective breathing pattern.

The nurse is caring for three children with cardiac conditions who are taking digoxin (Lanoxin). Prior to giving the medication, the nurse would check which lab results because of the risk for digoxin toxicity? A. Hemoglobin and hematocrit B. Potassium and magnesium C. Glucose and phosphorus D. BUN and platelets

B. Potassium and magnesium Hypokalemia and hypomagnesemia can increase the risk for digoxin toxicity. In children with altered renal function, the dose needs to be decreased. Glucose and phosphorus levels are not related to digoxin toxicity. An elevated BUN could indicate altered renal function and affect the digoxin level but not the platelet level. Hemoglobin and hematocrit are not related to digoxin toxicity.

2. A newborn baby with transposition of the great arteries has an echocardiogram performed to detect if any other defects are present in the heart. As the nurse, you know that what other defects can most commonly occur with TGA? Select all that apply: A. Complete atrioventricular canal defect B. Ventricular septal defect C. Patent ductus arteriosus D. Tricuspid atresia E. Tetralogy of fallot F. Atrial septal defect

B. Ventricular septal defect C. Patent ductus arteriosus F. Atrial septal defect The answers are B, C and F. Some babies may have slight communication between the right and left side of the heart in TGA, if another type of congenital defect is present (which many times this is the case). The other defects present in TGA may actually provide short-term benefits because it will allow unoxygenated blood to mix with oxygenated blood to enter the body. These other defects most commonly include: ventricular septal defect (doesn't allow much mixing), atrial septal defect, or patent ductus arteriosus (note the PDA is usually kept open on purpose after birth with a medication called prostaglandin E "alprostadil" to allow for more oxygenated blood to enter the body until surgery is performed).

2. A 4-month-old is diagnosed with Tetralogy of Fallot. You're providing an illustration to the parent to help him understand the pathophysiology of this condition. What defects must be present in the illustration to help the parent understand their child's condition? Select all that apply: A. Aortic stenosis B. Ventricular septal defect C. Coarctation of aorta D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis G. Patent ductus arteriosus

B. Ventricular septal defect D. Right ventricular hypertrophy E. Displacement of the aorta F. Pulmonic stenosis

4. You're performing a head-to-toe- assessment on a newborn with severe coarctation of the aorta. You note a systolic heart murmur. Where is this heart murmur best auscultated in a patient with this condition? A. at the 4th intercostal space left to the sternal border B. at the left interscapular area C. at the 2nd intercostal space right to the sternal border D. at the mid-subclavicular line right of the sternal border

B. at the left interscapular area The answer is B. The type of heart murmur generally present in CoA is a systolic murmur. It is best heard in the interscapular area on the left (which is the back near the shoulder blade).

5. You are assessing the heart sounds of a patient with a severe case of Tetralogy of Fallot. You would expect to hear a __________ murmur at the _______ of the sternal border? A. diastolic; right B. systolic; left C. diastolic; left D. systolic; right

B. systolic; left

1. A two-month-old is showing signs and symptoms of heart failure. An echocardiogram is ordered. The test shows the infant has a ventricular septal defect (VSD). Which statement below best describes the blood flow in the heart due to this congenital heart defect? A. "The blood in the heart is shunting from the right ventricle to the left ventricle, which is increasing pulmonary blood flow." B. "The blood in the heart is shunting from the left ventricle to the right ventricle, which is decreasing pulmonary blood flow." C. "The blood in the heart is shunting from the left ventricle to the right ventricle, which is increasing pulmonary blood flow." D. "The blood in the heart is bypassing the left ventricle and is being shunted to the right ventricle, which is decreasing lung blood flow."

C. "The blood in the heart is shunting from the left ventricle to the right ventricle, which is increasing pulmonary blood flow."

6. As the registered nurse you are developing a plan of care for a patient with Tetralogy of Fallot. Select all the appropriate nursing diagnoses below that would be specific to this patient: A. Risk for deficient fluid volume B. Ineffective airway clearance C. Activity Intolerance D. Failure to thrive E. Risk for impaired liver function

C. Activity Intolerance D. Failure to thrive The answers are C and D. A patient with TOF will have activity intolerance because remember this is a cyanotic heart defect where there is not enough oxygen in the blood (due to the structural defect of the heart) and any activity (feeding, crying, play etc.) can increase the demands for oxygen. Therefore, the patient will experience activity intolerance. In addition, the patient can experience failure to thrive because the constant hypoxemia (low oxygen in the blood) experienced can lead the child to have poor growth, weight loss, clubbing of the nails etc. Remember organs need plenty of oxygen to work and grow but in TOF this isn't happening very well. Options A, B, and E are not appropriate nursing diagnoses.

7. A newborn is taking Digoxin prior to surgical repair of a truncus arteriosus. You're assessing morning labs and the patient's Digoxin level is 1.8 ng/mL. The next dose of Digoxin is due at 1000. As the nurse you will? Select all that apply: A. Redraw a Digoxin level to confirm the morning lab level B. Hold the 1000 dose and notify the physician C. Administer the dose as ordered D. Administer the dose as ordered, but notify the physician about the abnormal level E. Check apical pulse prior to administration of the scheduled dose at 1000 F. Hold scheduled dose if apical pulse less than 60

C. Administer the dose as ordered E. Check apical pulse prior to administration of the scheduled dose at 1000 The answers are: C and E. A normal digoxin level is 0.5-2 ng/mL (the patient's digoxin level is normal in this scenario). Therefore, the nurse should ADMINISTER the dose as ordered.....AFTER checking the apical pulse. The nurse would hold the dose if the apical pulse was less than 90-110 beats per minute in an INFANT. It is less than 60 bpm for adults (that is why option F is wrong).

4. You're educating the parents of a patient with transposition of the great arteries about the treatment options. Which treatment option below provides a permanent solution and is performed within the first few weeks of life? A. Prostaglandin E infusion B. Balloon atrial septostomy C. Arterial switch procedure D. Complete repair with a patch

C. Arterial switch procedure The answer is C. This procedure is an open heart surgery where the pulmonary artery and aorta are switched back to where they should be along with their coronary arteries and is performed within the first few weeks of life. Options A and B are treatment options but are TEMPORARY until an arterial switch procedure can be performed. Option D is a treatment option for TOF (tetralogy of fallot) or ventricular septal defect.

6. You're working in the NICU providing care to a neonate who has a large patent ductus arteriosus. Which finding during your head-to-toe assessment would require you to immediately notify the physician?* A. Loud, harsh continuous murmur B. Abnormal pulse pressure C. Crackles D. Diaphoresis when feeding

C. Crackles The answer is C. Options A, B, and D (although are abnormal findings) is expected to be found in a large PDA. However, option C is a sign and symptoms that the patient is entering into left-sided heart failure (a life-threatening complication of this condition in a neonate), which would require immediate intervention. PDA can lead to heart failure when the left-to-right shunt is severe enough.

Education for the parents of children with cardiac problems is focusing on the primary therapy for secondary hypertension. Nursing care is correct if which instructions are provided? A. Eat a diet that contains low amounts of salt. B. Reduce body weight to a normal weight. C. Determine and then treat the underlying cause. D. Increase gentle exercise and therefore fitness.

C. Determine and then treat the underlying cause. Secondary hypertension is a result of an underlying disease process or structural abnormality. It is usually necessary to treat the problem before the hypertension will be controlled. The low-salt diet, weight reduction, and increased exercise and fitness are usually effective for essential hypertension. The low-salt diet, weight reduction, and increased exercise and fitness are usually effective for essential hypertension. The low-salt diet, weight reduction, and increased exercise and fitness are usually effective for essential hypertension.

3. Which of the following genetic disorders increases a patient risk of developing truncus arteriosus? A. Edward's syndrome (trisomy 18) B. Down syndrome C. DiGeorge syndrome D. Patau syndrome

C. DiGeorge syndrome

6. Your newborn patient has a severe case of transposition of the great arteries. The baby does not have any other defects and is therefore experiencing severe cyanosis and needs medical intervention immediately. The newborn is started on prostaglandin E and is scheduled for a balloon atrial septostomy. Select the statement below that best describes this procedure: A. During this procedure the pulmonary artery and aorta are switched along with their coronary arteries. B. This procedure will enlarge a hole in the ventricular septum and provide permanent treatment for this condition. C. During this procedure a hole in the atrial septum is enlarged, which will be temporary. D. The procedure will switch the pulmonary vein and aorta long with their coronary arteries, which will be permanent.

C. During this procedure a hole in the atrial septum is enlarged, which will be temporary. The answer is C. A balloon atrial septostomy (this is TEMPORARY UNTIL SURGERY is performed) is a procedure performed during a heart cath and is done to enlarge a hole in the atrial septum. A catheter is inserted into the heart through a vessel to enlarge the foramen ovale or an atrial septal defect already present in the interatrial septum. WHY? This allows unoxygenated and oxygenated blood to mix and enter systemic circulation and will be temporary until surgery can be performed.

4. While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to? A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.

C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. The answer is C. The patient is experiencing a "tet spell". This is where during any type of activity like feeding, crying, playing etc. the child's heart (due to Tetralogy of Fallot) is unable to maintain proper oxygen levels in the blood (these activities place extra work on the heart and it can't keep up). Therefore, there are low amounts of oxygen in the blood, and the skin will become cyanotic (bluish tint) and the respiratory rate will increase (this is the body's way of trying to increase the oxygen levels in the body but it doesn't work because it's not a gas exchange problem in the lungs but a heart problem). The nurse would want to place the infant in the knee-to-chest position. WHY? This increases systemic vascular resistance (which will help decrease the right to left shunt that is occurring in the heart...hence helps replenish the body with oxygenated blood). In addition, the nurse would want to place the patient on oxygen.

3. While assessing a newborn's heart sounds you note a loud murmur at the left upper sternal border. You report this to the physician who suspects the infant may have patent ductus arteriosus. The physician asks you to obtain a pulse pressure. If patent ductus arteriosus is present, the pulse pressure would be ___________.* A. Narrow B. Fluctuating C. Wide D. Normal

C. Wide The answer is C. The pulse pressure will be widened. Pulse pressure is the difference between the systolic and diastolic pressure and indicates the force the heart needs to contract. With PDA, the diastolic pressure will be low, which will widen the difference between the systolic and diastolic pressure. WHY? When blood is leaving through the extra vessel (patent ductus arteriosus) back into the pulmonary artery, this will decrease diastolic pressure (which is the pressure of the blood in the arteries when the heart if filling or in between heart beats). This will lead to a wide pulse pressure, hence a decrease is diastolic pressure and will then in turn lead to bounding pulses.

4. As noted in the previous question, a loud murmur was noted during assessment of a newborn with patent ductus arteriosus. As the nurse you know that what type of murmur is a hallmark sign of this condition?* A. harsh, loud systolic murmur B. soft, blowing diastolic murmur C. systolic and diastolic machinery-like murmur D. machinery-like murmur present on only diastole

C. systolic and diastolic machinery-like murmur The answer is C. The hallmark murmur with PDA is a continuous (heard both during diastole and systole) that is harsh and machinery-like. It can be noted at the left upper sternal border.

1. A newborn baby is born with transposition of the great arteries (TGA). You're explaining the condition to the parents. Which statement by the father demonstrates he understood the education provided about this condition? A. "The pulmonary vein and artery are switched, which causes the pulmonary vein to deliver unoxygenated blood to the systemic circulation while the pulmonary artery delivers oxygenated blood back to the lungs." B. "The aorta and pulmonary vein are switched, which causes the aorta to arise from the right ventricle and the pulmonary vein to arise from the left ventricle." C. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the left ventricle and the pulmonary artery to arise from the right ventricle." D. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the right ventricle and the pulmonary artery to arise from the left ventricle."

D. "The aorta and pulmonary artery are switched, which causes the aorta to arise from the right ventricle and the pulmonary artery to arise from the left ventricle."

8. As the nurse you know that if a patient has a large ventricular septal defect and does not receive treatment, the patient may develop Eisenmenger Syndrome. This syndrome causes? A. A reversal of blood shunting in the heart from right to left and will cause pulmonary hypertension. B. A reversal of blood shunting in the heart from left to right and will cause cyanosis. C. A reversal of blood shunting in the heart from left to right and will cause pulmonary hypertension. D. A reversal of blood shunting in the heart from right to left and will cause cyanosis.

D. A reversal of blood shunting in the heart from right to left and will cause cyanosis. The answer is D. If the VSD is not treated, (later on in life) a reversal of blood shunting (shunting from right to left) will occur due to the extensive pulmonary hypertension in a condition called Eisenmenger's Syndrome. With this shunting, unoxygenated blood will start to enter circulation and cyanosis and clubbing can start to be seen. It is irreversible and a lung or heart transplant is the current option.

8. You're caring for a newborn who has Tetralogy of Fallot with severe cyanosis. You anticipate the newborn will be started on ___________? A: Indomethacin B. Diclofenac C. Celecoxib D. Alprostadil

D. Alprostadil The answer is D. Alprostadil, prostaglandin E, will keep the ductus arteriosus open after birth. This will help with keeping the oxygen levels up because it allows more blood to flow to the lungs that is oxygenated via the ductus arteriosus. Remember this usually closes shortly after birth, but in a patient with severe Tetralogy of Fallot this opening needs to stay opened until surgery can be performed.

The nurse is caring for an infant with an acyanotic heart defect. Why must the nurse continue to monitor this infant's mucous membranes, fingers, and toes? A. Because it explains the hemodynamics involved B. Because cyanotic defects are easily identified C. Because that is part of the standardized assessment D. Because children with acyanotic heart defects may have cyanosis if another cardiac problem arises or if the current one becomes worse

D. Because children with acyanotic heart defects may have cyanosis if another cardiac problem arises or if the current one becomes worse Children with traditionally named acyanotic defects may be slightly cyanotic, and children with traditionally classified cyanotic defects may appear pink, although they may eventually become cyanotic. It is most important to document specific assessment findings and let the classification be specified by the cardiologist. The classification does not reflect the path of blood flow within the heart. Children with cyanosis may be easily identified, but that does not help with the diagnosis. Although these components are assessed regularly when an infant has a cardiac problem, the reason is that cyanosis can occur if the cardiac problem becomes worse in some cases.

8. An ACE inhibitor is ordered by the physician for an infant with truncus arteriosus. This medication will decrease afterload and help with the management of heart failure. Which medication below is an ACE inhibitor? A. Losartan B. Celiprolol C. Furosemide D. Catopril

D. Catopril

The mother of an infant who is to have surgery for a patent ductus arteriosus (PDA) asks what the beneficial effect of performing surgery is. Which statement by the nurse best explains prevention of which complication by performing the surgery? A. Pulmonary infection B. Right-to-left shunting of the blood C. Decreased workload on left side of the heart D. Increased pulmonary vascular congestion

D. Increased pulmonary vascular congestion A patent ductus arteriosus (PDA) allows blood to flow from the aorta (high pressure) to the pulmonary artery (low pressure). If the PDA stays open, increased pulmonary congestion can occur. The increased pulmonary vascular congestion is the primary complication. The blood is shunted left to right. The increased pulmonary vascular congestion is the primary complication.

A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. What position would the nurse expect the child to assume? A. Low Fowler's B. Prone C. Supine D. Knee-chest

D. Knee-chest The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate. Low Fowler's position would assist with respiratory issues but would not assist with the need for cardiac compensation. Prone does not offer any advantage to the child. Supine does not offer any advantage to the child.

4. You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair. This defect is causing complications. These complications are arising from an abnormal shunting of blood throughout the heart. As the nurse, you know that a __________________ shunt is occurring in the heart due to the defect. A. Right-to-left B. Right C. Left D. Left-to-right

D. Left-to-right

2. An infant has a large ventricular septal defect (VSD). The defect is located in the upper section of the ventricular septum and is near the tricuspid and aortic valve. Based on this description, what type of ventricular septal defect is this? A. Outlet (conal or subarterial) B. Muscular C. Inlet (atrioventricular) D. Membranous

D. Membranous

5. You're assessing the heart sounds of a child with an atrial septal defect. You note a heart murmur at the 2nd intercostal space at the left upper sternal border. Heart murmurs noted in patients with an atrial septal defect are called? A. Holosystolic murmurs B. Diastolic murmurs C. Early systolic murmurs D. Midsystolic murmurs

D. Midsystolic murmurs The answer is D. In patients with ASDs, the nurse may notice a midsystolic (also called systolic ejection murmur) at the 2nd ICS at the left sternal border. This is due to increased blood flow through the pulmonic valve. The murmur is quiet at the beginning of systole, increases mid-systole and then decreases at the end of systole...it ends before S2 . S2 is wide, fixed splitting due to the slowness of the pulmonic valve closing.

The mother of a child who is to have an echocardiogram asks what the test will do. Which explanation by the nurse is best? A. The procedure uses high-frequency sound waves created by a transducer to produce an image of cardiac structures. B. The heart's electrical impulses are recorded on a screen, and a paper copy is also made. C. Your child's heart vessels are measured with a catheter threaded into the heart. D. Your child's heart structures will be painlessly visualized using sound waves while your child lies quietly on an exam table.

D. Your child's heart structures will be painlessly visualized using sound waves while your child lies quietly on an exam table. This is the clearest explanation without using technical terms. Echocardiography uses high-frequency sound waves. The child must lie completely still. With the improvements in technology, diagnosis can sometimes be made without cardiac catheterization. The explanation is very technical. This is the description of electrocardiography, which is a tracing of the electrical path of the depolarization action of myocardial cells. This is the description of a cardiac catheterization, which is an invasive procedure in which a catheter is threaded into the heart.

4. TRUE or FALSE: The signs and symptoms of a ventricular septal defect are most commonly detected in a baby following birth. True False

False The answer is FALSE. Signs and symptoms of a ventricular septal defect are NOT commonly found in a baby after birth, but rather a little later on. VSD signs and symptoms most likely start to present around 1-3 months after birth. WHY? In utero, the baby has the same pressure on the right and left side of the heart. However, after birth the lungs start to work and this pressure changes gradually over the next 2-3 weeks. The pressure in the right side will decrease compared to the left side. Therefore, when a large VSD is present the pressure changes will cause blood to begin shunting from the LEFT ventricle to the RIGHT ventricle (hence increasing lung blood flow which leads to pulmonary hypertension and eventually heart failure). Therefore, at about 1-3 months of life the infant will be presenting with heart failure, growth problems, and respiratory issues.