Chapter 41 Peds
The nurse is developing a plan of care for an infant with heart failure who is receiving digoxin. The nurse would hold the dose of digoxin and notify the physician if the infant's apical pulse rate was: A) 140 beats per minute B) 120 beats per minute C) 100 beats per minute D) 80 beats per minute
Ans: D Feedback: In an infant, if the apical pulse rate is less than 90 beats per minute, the dose is held and the physician should be notified.
A nurse is reviewing the medical record of a child and finds that the child has a grade III murmur. After auscultating the child's heart sounds, the nurse would document this murmur as which of the following? A) Loud without a thrill B) Loud with a precordial thrill C) Soft and easily heard D) Loud, audible with a stethoscope
Ans: A Feedback: A grade III murmur is loud without a thrill. Grade II is soft and easily heard. Grade IV is loud with a precordial thrill. Grade V is characterized as loud, audible with a stethoscope.
After assessing a child's blood pressure, the nurse determines the pulse pressure and finds that it is narrowed. Which of the following would the nurse identify as associated with this finding? A) Aortic stenosis B) Patent ductus arteriosus C) Aortic insufficiency D) Complete heart block
Ans: A Feedback: A narrowed pulse pressure is associated with aortic stenosis. A widened pulse pressure is associated with patent ductus arteriosus, aortic insufficiency, fever, anemia, or complete heart block. '
A child with heart failure is receiving supplemental oxygen. The nurse understands that in addition to improving oxygen saturation, this intervention also helps to do which of the following? A) Cause vasodilation B) Increase pulmonary vascular resistance C) Promote diuresis D) Mobilize secretions
Ans: A Feedback: Oxygen improves oxygen saturation and also functions as a vasodilator and decreases pulmonary vascular resistance. Diuretics promote dieresis. Chest physiotherapy helps to mobilize secretions
After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which of the following as an assessment finding? A) Janeway lesions B) Jerky movements of the face and upper extremities C) Black lines D) Osler nodes
Ans: B Feedback: Sydenham chorea is a movement disorder of the face and upper extremities associated with acute rheumatic fever. Janeway lesions, black lines, and Osler nodes are associated with infective endocarditis.
The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which of the following findings would the nurse most likely expect to assess if the child had transposition of the great vessels? A) Significant cyanosis without presence of a murmur B) Abrupt cessation of chest output with an increase in heart rate/filling pressure C) Soft systolic ejection D) Holosystolic murmur
Ans: A Feedback: Significant cyanosis without presence of a murmur is highly indicative of transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic murmur can be found with other disorders, such as hypoplastic left heart syndrome, but is not highly suspicious of transposition.
A child is diagnosed with Kawasaki disease and is in the acute phase of the disorder. Which of the following would the nurse expect the physician to prescribe? Select all answers that apply. A) Intravenous immunoglobulin B) Ibuprofen C) Acetaminophen D) Aspirin E) Alprostadil
Ans: A, C, D Feedback: In the acute phase, high-dose aspirin in four divided doses daily and a single infusion of intravenous immunoglobulin are used. Acetaminophen is used to reduce fever. Nonsteroidal anti-inflammatory agents such as ibuprofen are avoided while the child is receiving aspirin therapy. Alprostadil is used to temporarily keep the ductus arteriosus patent in infants with ductal-dependent congenital heart defects.
The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. Which of the following would the nurse be least likely to include? A) Daily weight assessment B) Maintenance of strict bed rest C)Prevention of infection D) Signs of complications
Ans: B Feedback: A child with congenital heart disease should be allowed to engage in activity as tolerated, with rest periods frequently throughout the day to prevent overexertion. Daily weights, infection prevention measures, and signs of complications are all appropriate to include when teaching parents of a child with a congenital heart defect.
After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow? A) Tetralogy of Fallot B) Atrial septal defect C) Hypoplastic left heart syndrome D) Transposition of the great vessels
Ans: B Feedback: Atrial septal defect is an example of a disorder involving increased pulmonary blood flow. Tetralogy of Fallot is a defect involving decreased pulmonary blood flow. Transposition of the great vessels and hypoplastic left heart syndrome are examples of mixed disorders.
When conducting a physical examination of a child with suspected Kawasaki disease, which of the following would the nurse expect to assess? A) Hirsutism or striae B) Strawberry tongue C) Malar rash D) Café au lait spots
Ans: B Feedback: Dry, fissured lips and a strawberry tongue are common findings with Kawasaki disease. Acne, hirsutism, and striae are associated with anabolic steroid use. Malar rash is associated with lupus. Café au lait spots are associated with neurofibromatosis.
The nurse is assessing a child with suspected infective endocarditis. Which of the following assessment findings would the nurse interpret as a sign of extracardiac emboli? A) Pruritus B) Roth spots C) Delayed capillary refill D) Erythema marginatum
Ans: B Feedback: Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash associated with acute rheumatic fever.
The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which of the following statements by the mother would warrant further investigation? A) "My baby does not make any grunting noises." B) "The baby seems more comfortable over my shoulder." C) "The baby usually drinks all of her bottle." D) "I don't notice any rapid breathing patterns."
Ans: B Feedback: The nurse should be alert to statements indicating that the baby seems to be more comfortable when she is sitting up or over her mother's shoulder than when she is lying flat. Grunting or rapid breathing would be a cause for concern. Drinking all of the bottle would be considered normal.
The nurse is caring for an infant with suspected patent ductus arteriosus. Which of the following assessment findings would the nurse identify as helping to confirm this suspicion? A) Thrill at the base of the heart B) Harsh, continuous, machine-like murmur under the left clavicle C) Faint pulses D) Systolic murmur best heard along the left sternal border
Ans: B Feedback: With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually loudest under the left clavicle) is heard at the first and second intercostal spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the left sternal border point to aortic stenosis.
The nurse is conducting a physical examination of a child with a ventricular septal defect. Which finding would the nurse expect to assess? A)Right ventricular heave B)Holosystolic harsh murmur along the left sternal border C)Fixed split-second heart sound D)Systolic ejection murmur
Ans: B Feedback: With ventricular septal defects, there is often a characteristic holosystolic harsh murmur along the left sternal border. Right ventricular heave, fixed split-second heart sound, and systolic ejection murmur are typically found with atrial septal defects.
The nurse is reviewing the medical record of a child with infective endocarditis. Which of the following would the nurse expect to find? Select all answers that apply. A) White blood cell count revealing leukopenia B) Microscopic hematuria with urinalysis C) Electrocardiogram with prolonged PR interval D) Lungs clear on auscultation E) Petechiae on palpebral conjunctiva
Ans: B, C, E Feedback: With infective endocarditis, leukocytosis, microscopic hematuria, prolonged PR interval, adventitious lung sounds, and petechiae on the palpebral conjunctiva are noted.
Auscultation of a child's heart reveals a loud murmur with a precordial thrill. The nurse documents this as which of the following? A) Grade II B) Grade III C) Grade IV D) Grade V
Ans: C Feedback: A grade IV murmur is loud with a precordial thrill. A grade II murmur is soft and easily heard. A grade III murmur is characterized as loud without a thrill. A grade V murmur is characterized as loud, audible without a stethoscope.
A 9-year-old child has undergone a cardiac catheterization and is being prepared for discharge. The nurse is instructing the parents and child about postprocedure care. Which statement by the parents indicates that the teaching was successful? A) "This pressure dressing needs to stay on for 5 days from now." B) "He can't eat but he can drink fluids for the next 24 hours." C) "He should avoid taking a bath for about 3 days but he can shower." D) "It's normal if he says he feels like his heart skipped a beat."
Ans: C Feedback: After a cardiac catheterization, the child should avoid tub baths for about 3 days but he can shower or use sponge baths. The pressure dressing should be removed the day after the procedure and a dry sterile dressing or adhesive bandage is applied for the next several days. After the procedure, the child can resume his usual diet. Any reports of fluttering or the heart skipping a beat should be reported.
The nurse is caring for a 2-month-old infant who has been diagnosed with acute heart failure. The nurse is providing teaching about nutrition. Which of the following statements by the mother indicates a need for further teaching? A) "The baby may need as much as 150 calories/kg/day." B) "Small, frequent feedings are best if tolerated." C) "I need to feed him every hour to make sure he eats enough." D) "Gavage feedings may be required for now."
Ans: C Feedback: Although offering small frequent feedings is appropriate if the infant tolerates them, feeding every hour is not necessary. During the acute phase, continuous or intermittent gavage feedings may be needed to help the infant maintain or gain weight. Due to the increased metabolic demands, the infant may require as much as 150 calories/kg/day.
A child with a suspected cardiovascular disorder is to undergo diagnostic testing and is scheduled for an echocardiogram. When explaining this test to the child, which of the following would the nurse most likely include? A) "This test will check the pattern of how your heart is beating." B) "They'll take a picture of your chest to look at the heart's size." C) "A special wand that picks up sound is used to check your heart." D) "Small patches are attached to your chest to check the heart rhythm."
Ans: C Feedback: An echocardiogram is a noninvasive ultrasound procedure using a gel-coated wand that assesses the heart wall thickness, the size of the chambers, valve and septal motion, and the relationship of the great vessels to other cardiac structures. An electrocardiogram reveals the pattern or rhythm of the heart's beating and involves small patches or electrodes attached to the chest. A chest radiograph involves a radiographic film of the chest to determine the size of the heart and its chambers.
An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate? A) "That's true, but we'll make sure she gets the best intravenous nutrition." B) "Unfortunately, your baby needs more nutrients than what breast milk can provide." C) "Breast milk may help to boost her immune system, so you can continue to use it." D) "She won't be able to suck, so we have to give her fortified formula through a tube."
Ans: C Feedback: Breastfeeding a child before and after cardiac surgery may boost the infant's immune system, which can help fight postoperative infection. If breastfeeding is not possible, mothers can pump milk and the breast milk may be given via bottle, dropper, or gavage feeding. In addition, breastfeeding is associated with decreased energy expenditure during the act of feeding.
A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication? A) Alprostadil B) Heparin C) Indomethacin D) Spironolactone
Ans: C Feedback: Indomethacin is the drug typically ordered to close a patent ductus arteriosus. Alprostadil would be indicated to maintain the ductus arteriosus temporarily in infants with ductal-dependent congenital heart defects. Heparin would be used for prophylaxis and treatment of thromboembolic disorders, especially after surgery. Spironolactone would be used to manage edema due to heart failure and to treat hypertension.
A nurse is working with an adolescent who is slightly overweight and was recently diagnosed with hypertension. They are discussing nutritional management. Which statement by the adolescent demonstrates understanding of the information? A) "I have to make sure that I don't eat a lot of salty foods." B) "I can eat any amount at a meal as long as I don't eat between meals." C) "I should eat plenty of fresh fruits and vegetables." D) "If I skip breakfast, I can eat a much bigger lunch."
Ans: C Feedback: Nutritional management includes controlling portion sizes, decreasing the intake of sugary beverages and snacks, eating more fresh fruits and vegetables, and eating a healthy breakfast. Salt restriction and potassium or calcium supplements have not been shown to decrease blood pressure in children.
During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tell the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year-old is lost in the shuffle." Which nursing diagnosis would the nurse identify as most appropriate? A) Risk for delayed growth and development related to necessary treatments B) Deficient knowledge related to the care of a child with congenital heart disease C) Interrupted family processes related to demands of caring for the ill child D) Fear related to infant's cardiac condition and need for ongoing care
Ans: C Feedback: The statements by the parents indicate that there is disruption in the family resulting from the demands of caring for the ill infant and they verbalized concern about their older child. The child may be at risk for delayed growth and development, but this is not indicated by the parents' statements. The parents may lack knowledge about their infant's condition and they may be experiencing fear about the infant's condition, but the statements reflect issues related to the family functioning.
A 7-year-old child with a family history of cardiovascular disease is being screened for hyperlipidemia. When reviewing the child's laboratory test results, which total cholesterol level would be of significant concern? A) 120 mg/dL B) 150 mg/dL C) 180 mg/dL D) 210 mg/dL
Ans: D Feedback: A total cholesterol level greater than 200 mg/dL is considered high and would be of the greatest concern. Levels of 120 mg/dL and 150 mg/dL are considered within the normal range. A level of 180 mg/dL would be considered borderline and significant. However, a level greater than 200 mg/dL would be of greater concern.
The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? A) Contact the physician B) Offer a snack and administer another dose C) Immediately administer another dose D) Administer next dose as ordered in 12 hours
Ans: D Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should not give a second dose and should wait until the next scheduled dose. It is not necessary to contact the physician.