Chapter 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder
A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which statement by his mother may necessitate rescheduling of the procedure?
"He seems listless and slightly warm"
The nurse is reviewing nutritional recommendations with the parents of a teen diagnosed with hyperlipidemia. Which statements indicate an understanding of the recommended diet for this condition? Select all that apply.
"I should plan to have vegetables with each evening meal served." "Adding fresh fruits to my child's lunch is a good idea." "My child loves chicken and I can still serve it but I need to remove the skin."
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?
"It will determine if the heart is enlarged"
The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?
"It's great that you are providing nutritious meals, but smaller frequent meals will tire your child less and promote weight gain"
A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction?
"My child cannot have any thing to eat or drink after midnight the day of the test."
The parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best?
"The low blood oxygen levels from the heart defect cause the lack of oxygen to the fingers, causing these changes."
A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?
"This test will check how blood is flowing through the heart"
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"
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.
"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."
A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings?
"Your daughter has an innocent heart murmur, which is nothing to worry about"
A pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can do to reduce the risk of this type of condition occurring in her baby. What information should the nurse mention to this client?
"make sure you are fully immunized"
A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse?
"these wires and connected to the heart and will detect if your infant's heart gets out of rhythm"
The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant's body weight. The infant weighs 15.2 lb (6.9 kg). Calculate the infant's morphine sulfate dose. Record your answer using one decimal place.
0.7
The nurse takes an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant?
100 beats per minute
The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy?
100 to 120/70 to 80 mm Hg
The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply.
16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/mL from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse
A nurse is preparing to administer a prescribed dose of digoxin to an 6-month-old infant. After assessing the infant's apical pulse, the nurse decides to withhold the dose and notify the health care provider. The nurse bases this decision on which apical pulse rate?
80 beats/min
The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding?
90/64
The nurse is caring for a 1-day-old newborn with patent ductus arteriosus with the following vital signs: pulse 160, respirations 80, oxygen saturation 92%, retractions, and crackles noted in bilateral lungs. Which nursing actions are appropriate at this time? Select all that apply.
Administer furosemide. Initiate intravenous access. Apply oxygen via oxyhood. Begin indomethacin infusion.
The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?
Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl.
The nurse is educating an adolescent female at risk for hypertension. Which interventions will the nurse recommend? Select all that apply.
Increase hours of sleep. Avoid any smoking. Exercise on a daily basis. Maintain a healthy weight.
The nurse is caring for a child who is preparing to undergo an exercise stress test. Which interventions will be included in the care?
Monitor vital signs prior to the start of the test. Monitor vital signs at completion of the test. Remind child to verbalize any feelings of discomfort during the test.
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
The nurse is caring for a 3-month-old infant with history of congenital heart disease. The infant is brought to the emergency department with nausea and vomiting for 3 days. Admission laboratory results confirm dehydration. The nurse realizes that the dehydrated infant is at risk for:
a cerebrovascular accident (stroke)
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
The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level?
digoxin
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
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:
femoral pulse weaker than brachial pulse
A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent?
have the child be seen by the primary care provider
The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?
heart failure
The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works?
high-frequency sound waves are directed toward the heart
A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia?
increased RBC
When caring for a child with Kawasaki disease, the nurse would know that:
management includes the administration of aspirin and IVIG
The nurse is auscultating heart sounds of a child with a mitral valve prolapse. The nurse should expect which assessment finding?
mild to late ejection click at the apex
A nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin?
nausea and vomiting
A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?
notify the doctor immediately
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
peeling hands and feet; fever
The nurse is caring for a 6-year-old with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?
place the child in a knee-to-chest position
What would be the most important measure to implement for an infant who develops heart failure?
placing the infant in a semi-fowlers position
When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?
polycythemia
A nurse is developing the plan of care for a 7-year-old child diagnosed with congenital heart disease and a history of hypercyanotic spells. Which interventions would the nurse include in the child's plan of care to address these spells? Select all that apply.
providing supplemental oxygen giving parenteral morphine sulfate
A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta?
pulses weaker in lower extremities compared to upper extremities
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?
tetralogy of fallot
A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?
the child will need the blood pressure checked two more time
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 in right-sided heart failure
The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. What would be included in the intervention strategies?
the nurse would review the child's 24-hour diet recall
A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?
this is caused by an opening that usually closed by 1 week of age
Parents are told that their infant has a heart defect with a left-to-right shunt. What is the best way for the nurse to explain this type of shunting to the parents?
this type of shunting causes an increase of blood to the lungs
A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers?
aspirin
When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?
tachycardia
Which nursing diagnosis would best apply to a child with rheumatic fever?
activity intolerance due to the inability of the heart to sustain extra workload
A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant?
administer oxygen
The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate?
apply pressure 1 inch above the site
The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first?
assess blood pressure in all extremities
Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?
assessing for the presence of femoral pulses
A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?
avoid drawing a blood specimen from the right femoral vein before the procedure
What information would be included in the care plan of an infant in heart failure?
begin formulas with increased calories
A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note?
bounding pulse
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?
digoxin
An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply?
ineffective tissue perfusion related to inefficiency of the heart as a pump
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?
initiate intravenous access
A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. What should the nurse tell the mother?
insertion of a catheter with an undefeated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions
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
Which nursing diagnosis will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?
risk for ineffective cardiopulmonary tissue perfusion
The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority?
swab throat for culture
At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?
taking pedal pulses for the first hours
The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason?
to build the blood levels to a therapeutic level
The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?
wheezing
