Maternal newborn/ Peds Test 4 study guide
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement?
"His stomach can hold approximately 10 ounces."
A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct?
"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."
The nurse is reviewing the laboratory test results of a newborn. Which results would the nurse identify as normal? Select all that apply.
- hemoglobin 17 g/dL - platelets 200,00 u/L-red blood cells 5.3 (1,000,000/uL) -white blood cells 8,000 /mm3
The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation?
"Was the baby recently crying?"
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 providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?
*"The feeling of the heart skipping a beat is common." "We need to avoid a tub bath for the next 3 days." "Strenuous activity should be limited for the next 3 days." "We need to watch for changes in skin color or difficulty breathing."
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?
*Digoxin Alprostadil Furosemide Indomethacin
A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.
-Fundus one fingerbreadth below the umbilicus-Moderate saturation of peripad every 3 hours
A nurse is doing an admission assessment on a female newborn. Which findings would warrant notification of the physician? Select all that apply.
-Scaphoid abdomen-Head circumference of 38 cm
The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.
-Yellowish gold color -Stringy to pasty consistency
Signs and symptoms of a postpartum infection
1.Temperature increase of 100.4 or higher on any 2 consecutive days of the first 10 days post-partum, not including the first 24 hours. 2. Foul smelling lochia, discharge 3. Malaise, Anorexia, Tachycardia, chills 4. Pelvic Pain 5. Elevated WBC
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?
108 beats/minute
normal vital sign values for full-term newborns
110-160 bpm, sleep= as low as 100 bpm, crying= up to 180 bpm, counted for a full minute. Pulse 30-60 rpm respirations Axillary= 36.4C-37.2C (97.5F-99F)Skin= 36C-36.5C (96.8F-97.7F) Temp 70-50/45-30 at birth, 90/60 at day 10 BP Greater than or equal to 40 mg% blood glucose
The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period?
5 at 1 minute; 6 at 5 minutes
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
5% to 10% of their birth weight
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?
500 additional calories per day
The nurse performs a quick assessment of an infant who is now 5-minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize?
5; repeat Apgar scoring in 5 minutes
A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?
6
Review APGAR scoring
A = appearance (color) P = pulse (heart rate) G = grimace (reflex irritability) A = activity (muscle tone) R = respiratory (respiratory effort)
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
A nurse is preparing to administer Vitamin K injection to a newborn. Which of the following is an appropriate response by the nurse to the newborn's mother regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C. "It is a preventative vaccine." D. "It provides immunity."
A. "It assists with blood clotting."
neurologic development in newborns
Acute senses of hearing, smell, taste, touch, and vision Adaptations of respiratory, circulatory, thermoregulatory, and musculoskeletal systems indirectly indicating central nervous system transition Reflexes: indication of neurologic development and function
A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant?
Administer oxygen.
What are some ways we help babies maintain their temperature?
Maintain neutral thermal environment and reduce heat loss. Monitor temperature carefully. Maintain axillary temperature of 97.7- 99.2 F. Avoid stressing the infant. Encourage skin to skin contact with mother. Promote early breastfeeding.
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?
Conduction
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. giving a Vit K injection B. initiating breastfeeding C. covering the newborns head with a cap D. performing the initial bath
C. covering the newborns head with a cap Rationale: The greatest risk to the newborn is cold stress. Therefore the highest priority intervention is to prevent heat loss. Covering the newborn's head with a cap prevents cold stress due to excessive evaporative heat loss.
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?
Ask the client when she last changed her perineal pad.
Medication education on which drug should the nurse provide to the caregivers of a child diagnosed with rheumatic fever?
Aspirin
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
Atony
The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?
Baby sleeps with the mother in bed.
What does the treatment for pulmonary stenosis involve?
Balloon dilation valvuloplasty is performed via cardiac catheterization to dilate the valve. This is effective in all but the most severe of cases, which will require surgical valvotomy.
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?
Bathe the baby under a radiant warmer.
What information would be included in the care plan of an infant in heart failure?
Begin formulas with increased calories.
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
Breastfeed the infant every 2-4 hours on demand
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?
Bringing the newborn into the room
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone
C. Erythromycin
A newborn was not dried completely after delivery. The nurse should understand that which of the following mechanisms causes the newborn to lose heat? A. Conduction B. Convection C. Evaporation D. Radiation
C. Evaporation Rationale: Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin.
Rheumatic fever
Delayed sequela of group A streptococcal pharyngeal infection •Diagnosis is based on the modified Jones criteria
normal/abnormal lochia
Lochia Rubra- Bright to dark red Lochia Serosa- Pink/brown Lochia Alba- yellow/white/clear Rubra - 2-4days pp Serosa - day 3 to day 10 or 13pp Alba - 4-8 wks pp •Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss •Light or small: an approximately 4-in stain or a 10- to 25-mL loss •Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL •Large or heavy: a pad is saturated within 1 hour after changing it
A nursing student is reviewing information about medications used to treat congestive heart failure in children. The student demonstrates understanding of the information by identifying which drug as prescribed to increase myocardial contractility?
Digoxin
Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?
During the first 24 hours after delivery owing to dehydration from exertion
A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?
Elevate the head of the bed. *Notify the doctor immediately. Administer epinephrine. Observe vitals every two hours.
What medications do newborns receive after they are born and why?
Erythromycin- prevent eye infection Vitamin K- prevent hemorrhagic disorders Hepatitis B- Protect against hepatitis B
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?
Evaporative
What are some things you can do as the nurse to help with breastfeeding?
Have a written breastfeeding policy that is communicated to all staff. Ensure that staff have sufficient knowledge, competence, and skills to support breastfeeding. Discuss the importance and management of breastfeeding with pregnant women and their families. Facilitate immediate and uninterrupted skin-to-skin contact, and support mothers in initiating breastfeeding as soon as possible after birth. Support mothers in initiating and maintaining breastfeeding, and manage common difficulties. Demonstrate to all mothers how to initiate and maintain breastfeeding. Encourage breastfeeding on demand. Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers. Establish breastfeeding support groups and refer mothers to them. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.
Help the mother initiate breastfeeding within 30 minutes of birth. • Encourage breastfeeding of the newborn infant on demand. • Place baby in uninterrupted skin-to-skin contact with the mother.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?
MORO
The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?
Hep B
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
An infant with a diagnosis of tetralogy of Fallot becomes agitated following a venous blood draw. Cyanosis with rapid, shallow respirations results. What is the priority nursing intervention?
Hold the child in the knee-chest position on one's shoulder.
Understand meconium
Meconium should be passed within the first 24 to 48 hrs.
Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?
Moderate
The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize?
Move the infant away from the window.
What is grunting? What is nasal flaring? What is acrocyanosis?
Nasal flaring, chest retractions Grunting on exhalation, labored breathing Generalized cyanosis, flaccid body posture
The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation?
Neurologic dysfunction
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity.
What are some important teaching points for parent's when putting their newborn to sleep?
No bumper pads, loose linens, or toys in the bassinet SIDS incidence higher with co-sleeping need for immunizations as a measure to prevent SIDS Place infant on their back to sleep
What's the treatment for a patent ductus arteriosis?
PDA is closed by coil embolization or device via cardiac catheterization. May also be surgically ligated
A child is diagnosed with tetralogy of Fallot and during a temper tantrum turns blue. What should the nurse do first?
Place child in the knee-to-chest position.
During assessment of an infant diagnosed with tetralogy of Fallot, the nurse notes bluish colored lips and irritability. Which nursing action is priority?
Place in knee-chest position.
The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?
Prevent infection of the eyes from vaginal bacteria
When caring for a child with heart failure, what are some appropriate nursing diagnoses and how would you explain them to parents?
Promoting oxygenation Supporting cardiac function Providing adequate nutrition Promoting rest Give smaller meals with snacks to get them to eat better. Give high protein, high carbs, and high amount so Ineffective airway related to heart defect as evidenced by clubbing
An infant with congenital heart disease is not growing and developing adequately. The nurse will institute what feeding strategy?
Raise the caloric density of the feeding beyond 20 calories per ounce.
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?
Reflex
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?
Resume intercourse if bright-red bleeding stops.
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
A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?
Serum sodium level Erythrocyte sedimentation rate *Serum potassium level Oxygen saturation level
Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?
Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.
A woman has just given birth vaginally to a newborn. Which action would the nurse do first?
Suction the mouth and nose.
The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in its bed, lying on its side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?
Sudden infant death syndrome
A nurse is caring for a child who is experiencing heart failure. Which assessment data was most likely seen when initially examined?
Tachycardia
What are some s/s of illness in newborns?
Temperature above 38 C (100.4 F) Poor feeding or little interest in food forceful vomiting or frequent vomiting decreased urination diarrhea or decreased bowel movements labored breathing with flared nostrils or an absence of breathing for greater than 15 seconds jaundice cyanosis lethargy inconsolable crying difficulty waking bleeding or purulent drainage around umbilical cord or circumcision drainage developing in eyes
A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?
The breakdown of RBCs release bilirubin, which the liver cannot excrete.
Assessment of a patient with coarctation of the aorta
The extent of the symptoms depends on the severity of the coarctation. Some children with coarctation of the aorta grow well into the school-age years before the defect is discovered.
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.
A nurse is caring for a child that just had open-heart surgery and the parents are asking why there are wires coming out of the chest of the infant. What is the best response by the nurse?
These wires are connected to the heart and will detect if your child's heart gets out of rhythm.
Parents are told their infant has a hypoplastic left heart. How would the nurse explain this condition to the family?
This is a problem where the left side of the heart did not develop properly.
A mother asks why her infant with a cyanotic heart defect turns blue. What is the best response by the nurse?
This is due to a decreased amount of oxygen to the peripheral tissue.
A parent is told 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 parent?
This type of shunting causes an increase of blood to the lungs.
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
Newborn weight loss
To gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age The infant has a 5-10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake.
What's a common assessment finding in newborns born via C-section?
Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section.
A nurse is assessing a 37-week gestation newborn born by cesarean section, and now at 4 hours of age on room air. The newborn had no breathing problems at birth. The nurse notes the following signs: expiratory grunting, flaring of the nares, mild cyanosis, and respirations of 120 bpm. The newborn is most likely experiencing:
Transient tachypnea of the newborn.This is a clear picture of how transient tachypnea of the newborn presents. In TTN, tachypnea is usually present by 6 hours of age, with respiratory rates as high as 100-140 bpm. It is more prevalent in cesarean births and near-term infants.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
Venous duplex ultrasound of the right leg
How do you know if a baby is getting enough milk from breast-feeding?
Watch the babies ques: hand-to-mouth movements, sucking motions, rooting, mouthing all signs of hunger Also watch for signs of the baby being satisfied: sleeping, calm. Also watch babies output
Assisting in the initiation of breast-feeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding?
Within the first 30 minutes after birth
Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
assess and massage the fundus.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:
acrocyanosis.
A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?
an ice pack applied to the perineum
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?
blood pressure
A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?
conduction
A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level?
on admission to the nursery
The nurse is planning care for an infant with a nursing diagnosis of decreased cardiac output related to a cardiac defect. What is the most appropriate outcome for this nursing diagnosis? The child will:
demonstrate stable vital signs, capillary refill less than 3 seconds, and a urine output of 1-2 mL/kg/hr.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?
hemorrhage
Review and know the risk factors for postpartum
hemorrhage: precipitous/quick labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor (>30 min), multiparity, and uterine overdistention from a large infant, twins, or polyhydramnios
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?
lack of thoracic compressions during birth
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:
maintain previous household routines to prevent infection.
A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?
mastitis
Understand hypoglycemia and measure to take to prevent
monitor for jitteriness, twitching, a weak abnormal cry, irregular respiratory effort, cyanosis, lethargy have mom breastfeed immediately or give donor milk or formula to elevate blood glucose levels
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
n assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?
negative attachment
Evaluating parents' understanding of newborn care
nurse should assess family for readiness of home care for the newborn - assess if they have previous newborn experience/knowledge, for parent-newborn attachment, adjustment so far to parental role, social support received, educational needs indicated, sibling rivalry issues, readiness of the parents to have their home/lifestyle altered to accommodate newborn, parents ability to verbalize/demonstrate newborn care following teaching
A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?
placenta removed via manual extraction
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?
policies that discourage unwrapping and exploring the infant
A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?
pulmonary embolism
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:
pulmonary embolism.
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:
this is a normal finding.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?
thromboembolic disorder of the lower extremities
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?
touching
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
Jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood Three groups of jaundice based on mechanism of accumulation of bilirubin Overproduction Decreased conjugation Impaired excretion
Care for a child with tetralogy of Fallot
• Avoid BP measurements and venipunctures in the affected arm after a Blalock-Taussig shunt. Pulse will not be palpable in that arm because of use of the subclavian artery for the shunt. • Monitor for ventricular arrhythmias after corrective repair.
What's the treatment for hypoplastic left heart syndrome?
• Heart transplantation is the treatment of choice. • Palliative staged treatment. First: Norwood procedure, reconstruction of the aorta and pulmonary arteries includes a cardiac transplant. Second: bidirectional Glenn procedure, connection of the superior vena cava to the right pulmonary artery to increase the blood flow to the lungs. Third: modified Fontan procedure
Treatments for ASDs or VSDs?
• If small, the defect may be sutured closed. Larger defects may require a patch of pericardium or synthetic material. • Ostium secundum ASD may be repaired percutaneously via cardiac catheterization with a septal occluder. • If surgical closure is required, it should be performed before permanent pulmonary vascular changes develop. • Surgical closure may be in the form of suture closure of the VSD, transcatheter placement of a device in the defect, or Dacron patch closure.
Review the 4 types of heat loss
•Conduction •Convection •Evaporation: •Radiation
What should you include in the plan of care for a child with heart defect?
•Improving oxygenation •Promoting adequate nutrition •Assisting the child and family with coping •Providing postoperative nursing care •Preventing infection •Providing child and family education
What is the priority nursing diagnosis in the plan of care for a child with a congenital heart disorder?
Ineffective Tissue Perfusion related to inadequate cardiac output
What is puerperal bradycardia?
40 to 80 beats for the first 6-10 days post delivery, related to a decreased cardiac effort, decreased blood volume, increased stroke volume. this is normal.
The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?
Ineffective airway clearance related to mucus and secretions
When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate?
30 to 60 breaths/min
A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?
37.0° C (98.6° F)
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 uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this?
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.
A shunt is being placed on a child with pulmonary atresia. What is the best explanation of this procedure to the parents?
The surgery will increase the blood flow to the lungs.
In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.
-women on antithyroid medications -women on antineoplastic medications -women using street drugs
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:
140 beats per minute. 120 beats per minute. 100 beats per minute. *80 beats per minute.
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 WBC Decreased RBC Decreased WBC *Increased RBC
The nurse is caring for a child with rheumatic fever who has polyarthritis. Which lab result would the nurse most anticipate with this child's diagnosis and symptoms?
Increased erythrocyte sedimentation rate (ESR)
A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication?
Indomethacin
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.
Possible labs of children who have cardiac disorders
Note increased hematocrit, hemoglobin, and RBC count associated with polycythemia. Echocardiography Electrocardiogram (ECG) Cardiac catheterization and angiography
The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?
30 mg/dL
The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?
Rooting
While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as:
Jaundice
A nurse is explaining the Apgar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply.
- It is done at 1 and 5 minutes after birth.-The baby is considered vigorous if the 5-minute score is above 7.-The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation.
Common medications used to treat heart disease. Important things to watch with these medication.
Alprostadil (prostaglandin)-• Monitor arterial BP, respiratory rate, heart rate, ECG, temperature, and pO2; watch for abdominal distention. • Fresh IV solution required every 24 hours. • Contraindicated in respiratory distress syndrome or persistent fetal circulation. Digoxin (cardiac glycoside, antiarrhythmic agent)-• Prior to administering each dose, count apical pulse for 1 full minute, noting rate, rhythm, and quality. Withhold if apical pulse is <60 bpm in an adolescent, <90 bpm in an infant. • Avoid giving oral form with meals, as altered absorption may occur. • Note signs of toxicity: nausea, vomiting, diarrhea, lethargy, and bradycardia. Furosemide (loop diuretic)-• Administer with food or milk to decrease GI upset. • Monitor BP, renal function, electrolytes (particularly potassium), and hearing. • May cause photosensitivity. Heparin (anticoagulant)- • Administer SQ, not IM. • Dose is adjusted according to coagulation test results. • Monitor for signs of bleeding, platelet counts. • Ensure that the antidote, protamine sulfate, is available. • Do not administer with uncontrolled bleeding or if subacute bacterial endocarditis is suspected. Indomethacin (nonsteroidal anti-inflammatory agent)-• Monitor heart rate, BP, ECG, and urine output; monitor for murmur. • Monitor serum sodium, glucose, platelet count, BUN, creatinine, potassium, and liver enzymes. • May mask signs of infection. • Note development of edema Spironolactone (potassium-sparing diuretic)-Administer with food. • Monitor serum potassium, sodium, and renal function. • May cause drowsiness, headache, and arrhythmia.
The young preschool child has congestive heart failure and receives digoxin elixir every 12 hours. The child's apical pulse is 80 beats per minute (bpm) with quiet activity. What will be the next action of the nurse?
Hold the dose and notify the practioner of the heart rate.
While reviewing a newborn's hospital record, which of the following would be most important for you to locate?
If he breathed spontaneously at birth
What are some ways parents can help their child with a cardiac disorder maintain a healthy weight?
Increase the caloric intake of the fluid that will not cause fluid overload.
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?
Lethargy and hypotonia
An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?
Tachypnea
