chapter 19

A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant? Administer antidiuretic. Provide large, less frequent feedings. Restrict fluids. Administer oxygen.

Administer oxygen. Explanation: If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.

A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting? Feeding problems Bradypnea Bradycardia Yellowish color

Feeding problems Explanation: The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.

The primary health care provider has prescribed intravenous furosemide for a child diagnosed with congestive heart failure (CHF). Which action will the nurse take when administering this medication? Administer with 10% dextrose solution. Infuse no more than 4 mg per minute. Monitor respirations during administration. Assess glucose levels.

Infuse no more than 4 mg per minute. Explanation: Diuretics such as furosemide, along with fluid restriction in the acute stages of CHF, help to eliminate excess fluids in the child with congestive heart failure. The nurse would administer no more than 4 mg of IV furosemide per minute to prevent ototoxicity. Furosemide should be diluted in D5W, NS, or LR solutions. Respirations should be monitored frequently in this client, but it is not necessary to monitor while administering the medication. Glucose levels should be monitored in clients with diabetes only.

The nurse is assessing a child with suspected rheumatic fever. What assessment findings are consistent with the disease process? Select all that apply. Diastolic murmur Involuntary limb movement Macular rash on trunk Tender swollen joints Nonpalpable subcutaneous nodules

Involuntary limb movement Macular rash on trunk Tender swollen joints Explanation: Signs and symptoms of rheumatic fever include systolic murmur, involuntary limb movement, macular rash on the trunk, tender swollen joints, and subcutaneous nodules.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? Leukopenia Polycythemia Increased platelet level Anemia

Polycythemia Explanation: Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated. Leukopenia, increased platelets, and anemia are not associated with tetralogy of Fallot.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? surgical site infection risk acute parental anxiety fluid overload risk altered cardiopulmonary tissue perfusion risk

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

A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child? lower extremities face presacral region hands

lower extremities Explanation: Edema of the lower extremities is characteristic of right ventricular heart failure in older children. In infants, peripheral edema occurs first in the face, then the presacral region, and the extremities.

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? coarctation of aorta tetralogy of Fallot pulmonary stenosis aortic stenosis

tetralogy of Fallot Explanation: Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed? "We can stop the penicillin when her symptoms disappear." "If she needs dental surgery, we might need additional medication." "She needs to take the drug for the full 14 days." "To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years."

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

The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply. "Our child will be so excited to get back to soccer league in a few days." "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "It's wonderful that our child will never have an abnormal heart rhythm again." "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed."

"We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." Explanation: With the Gore® Helex device, strenuous activity should be avoided for 2 weeks after the procedure, so neither soccer or bicycle riding would be allowed. Children should be monitored for the possible presence of atrial arrhythmias (lifelong) after surgical closure for the defect. Infection is a complication that must be monitored for and reported to the physician, and medications must be given as prescribed.

What information would be included in the care plan of an infant in heart failure? Encourage larger, less frequent feedings. Begin formulas with increased calories. Maintain child in the supine position. Administer digoxin even if the infant is vomiting.

Begin formulas with increased calories. Explanation: Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

While assessing a neonate with a ventricular septal defect (VSD), the nurse notes crackles and retractions. The nurse obtains the following vital signs: temp 100.2°F (38°C), pulse 134 bpm, respirations 64 breaths/minute, oxygen saturation 97% on room air. What will the nurse do first? Advise the mother to bottle feed. Give furosemide intravenously. Administer acetaminophen rectally. Apply oxygen 10 liters/min (LPM) via oxyhood.

Give furosemide intravenously. Explanation: The nurse's first action when a neonate with a cardiac disorder is experiencing signs of fluid overload but has a normal oxygen saturation is to administer a diuretic such as furosemide. Oxygen could be applied if the furosemide was not effective in reducing fluid overload or if the oxygen saturation was low. This will remove fluid from the lungs, allowing the infant to breathe more easily. Although the neonate has an elevated temperature, administration of acetaminophen does not take priority over breathing. If the neonate continues to show signs of pulmonary overload, the nurse could advise the mother to give expressed breast milk through a bottle or nasogastric tube

While assessing a neonate with a ventricular septal defect (VSD), the nurse notes crackles and retractions. The nurse obtains the following vital signs: temp 100.2°F (38°C), pulse 134 bpm, respirations 64 breaths/minute, oxygen saturation 97% on room air. What will the nurse do first? Advise the mother to bottle feed. Give furosemide intravenously. Administer acetaminophen rectally. Apply oxygen 10 liters/min (LPM) via oxyhood.

Give furosemide intravenously. Explanation: The nurse's first action when a neonate with a cardiac disorder is experiencing signs of fluid overload but has a normal oxygen saturation is to administer a diuretic such as furosemide. Oxygen could be applied if the furosemide was not effective in reducing fluid overload or if the oxygen saturation was low. This will remove fluid from the lungs, allowing the infant to breathe more easily. Although the neonate has an elevated temperature, administration of acetaminophen does not take priority over breathing. If the neonate continues to show signs of pulmonary overload, the nurse could advise the mother to give expressed breast milk through a bottle or nasogastric tube.

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority? Place the child on a soft diet. Initiate intravenous access. Administer acetaminophen. Assess cervical lymph nodes.

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

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority? Place the child on a soft diet. Initiate intravenous access. Administer acetaminophen. Assess cervical lymph nodes.

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

When educating the family of an ill infant with an atrioventricular canal defect/septal defect, what information would be included in the education if the doctor is planning on performing palliative care until the infant is healthier? Palliative pulmonary artery banding should help the infant grow. Most infants do not need surgical repair for this if palliative procedures are performed. The medication indomethacin is used to try to close the hole. VSD patching surgery should be performed immediately.

Palliative pulmonary artery banding should help the infant grow. Explanation: Palliative pulmonary artery banding should help the infant grow enough so that the atrioventricular canal defect can be repaired. The pulmonary artery banding will help, but the defect will still need to be fixed. Most infants will need surgery for a large, symptomatic VSD. The medication indomethacin is used for a PDA.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? Peeling hands and feet; fever Decreased heart rate and impalpable pulse Irritability and dry mucous membranes Low blood pressure and decreased heart rate

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

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure? Tachycardia Bradycardia Inability to sweat Splenomegaly

Tachycardia Explanation: Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding? The liver size increases due to cardiac medications. The spleen size increases due to frequent infection. The liver size increases in right-sided heart failure. The spleen size increases due to increased destruction of red blood cells.

The liver size increases in right-sided heart failure. Explanation: The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

A health care provider and other health team members are discussing congenital heart disorders that increase pulmonary blood flow. Which disorders are topics for this discussion? Select all that apply. Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Pulmonary stenosis Coarctation of the aorta

Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Explanation: Congenital heart defects classified as disorders with increased pulmonary blood flow include ventricular septal defect, patent ductus arteriosus, and atrioventricular canal defect. Pulmonary stenosis and coarctation of the aorta are classified as disorders with obstruction to blood flow.

The nurse receives the shift report of multiple pediatric clients. Which pediatric client will the nurse see first? an infant whose parents report difficulty feeding with a temperature of 100.1°F (38°C) a toddler with tetralogy of Fallot squatting quietly in the corner of the room a child with history of hypertension and a current blood pressure of 130/90 mm Hg an adolescent with coarctation of the aorta with reports of coughing and coryza

a toddler with tetralogy of Fallot squatting quietly in the corner of the room Explanation: The first child the nurse will see is the child showing signs and symptoms of decreased pulmonary blood flow and possible hypercyanotic (tet) spell, which includes a toddler with tetralogy of Fallot squatting. Squatting increases systemic vascular resistance and forces blood to flow through the narrow pulmonary valve to improve oxygenation. An infant with difficult feeding and an elevated temperature may have an infection but could be seen after addressing a potential respiratory/circulatory issue. The child with history of hypertension who has an elevated blood pressure can be seen later because this is an expected finding and not life-threatening. The adolescent with coarctation of the aorta being seen for coughing and coryza without any other signs of distress can also be seen later.

A nurse is providing care to a child with Kawasaki disease. Which medication(s) would the nurse expect the health care provider to prescribe? Select all that apply. aspirin ibuprofen abciximab IV immunoglobulin corticosteroids

aspirin IV immunoglobulin Explanation: Management of the child with Kawasaki disease includes a high dose of IV immunoglobulin therapy to relieve the symptoms and prevent coronary artery abnormalities, along with aspirin to control inflammation and fever. Aspirin may be continued for as long as 1 year in lower doses as an antiplatelet.

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

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

When caring for a child with Kawasaki disease, the nurse would know that: management includes administration of aspirin and IVIG. joint pain is a permanent problem. antibiotics should be administered every 8 hours by IV. steroid creams are used for the hand peeling.

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

A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers? nonsterioidal anti-inflammatory drugs (NSAIDs) antiviral insulin phenytoin

nonsterioidal anti-inflammatory drugs (NSAIDs) Explanation: Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids. Insulin would be given for diabetes and phenytoin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

A newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the mother, which defect would the nurse's description include? atrial septal defect stenosis of the aorta overriding of the aorta left ventricular hypertrophy

overriding of the aorta Explanation: One of the components in the tetralogy of Fallot is the overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with four components. The defects in the tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta, and left ventricular hypertrophy are not components of tetralogy of Fallot.

Which finding(s) is a major criterion used to help the health care provider diagnose acute rheumatic fever in a child? Select all that apply. elevated erythrocyte sedimentation rate temperature of 101.2°F (38.4°C) painless nodules located on the wrists pericarditis with the presence of a new heart murmur heart block with a prolonged PR interval

painless nodules located on the wrists pericarditis with the presence of a new heart murmur Explanation: Subcutaneous nodules and carditis are considered major criteria used in the diagnosing of acute rheumatic fever. The other options are minor criteria.

The nurse is implementing the plan of care for a child with acute rheumatic fever. What treatment(s) would the nurse expect to administer if prescribed? Select all that apply. penicillin corticosteroids nonsteroidal anti-inflammatory drugs digoxin intravenous immunoglobulin

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

A nurse is reading a journal article about congenital heart conditions that are associated with decreased pulmonary blood flow. The nurse demonstrates understanding of the information when she identifies which anomalies as being associated with tetralogy of Fallot? Select all that apply. pulmonary stenosis atrial septal defect overriding aorta right ventricular hypertrophy patent ductus arteriosus

pulmonary stenosis overriding aorta right ventricular hypertrophy Explanation: Tetralogy of Fallot is a congenital heart defect composed of four heart defects: pulmonary stenosis (a narrowing of the pulmonary valve and outflow tract, creating an obstruction of blood flow from the right ventricle to the pulmonary artery); ventricular septal defect; overriding aorta (enlargement of the aortic valve to the extent that it appears to arise from the right and left ventricles rather than the anatomically correct left ventricle); and right ventricular hypertrophy (the muscle walls of the right ventricle increase in size due to continued overuse as the right ventricle attempts to overcome a high-pressure gradient).

A child has been admitted to the inpatient unit to rule out acute Kawasaki disease. A series of laboratory tests have been ordered. Which findings are consistent with this disease? Select all that apply. reduced hemoglobin levels reduced white blood cell count elevated erythrocyte sedimentation rate (ESR) negative C-reactive protein levels reduced platelet levels

reduced hemoglobin levels elevated erythrocyte sedimentation rate (ESR) Explanation: Kawasaki disease is an acute systemic vasculitis occurring mostly in children 6 months to 5 years of age. It is the leading cause of acquired heart disease among children. The CBC count may reveal mild to moderate anemia, an elevated white blood cell count during the acute phase, and significant thrombocytosis (elevated platelet count [500,000 to 1 million]) in the later phase. The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are elevated.

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. What would the nurse expect to find? Select all that apply. tiring easily when eating shortness of breath when playing crackles on lung auscultation bradycardia hypertension

tiring easily when eating shortness of breath when playing crackles on lung auscultation Explanation: Manifestations of heart failure include difficulty feeding or eating, becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.