NCLEX-PN CARDIAC PEDIATRIC

The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply. 1."My baby's cheeks turn red when he cries." 2."I'm chilly but my baby's forehead is sweaty." 3."My baby doesn't seem to have any difficulty breathing." 4."I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." 5."My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

"I'm chilly but my baby's forehead is sweaty." "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? 1."I will not mix the medication with food." 2."If more than one dose is missed, I will call the doctor." 3."I will take my child's pulse before administering the medication." 4."If my child vomits after medication administration, I will repeat the dose."

"If my child vomits after medication administration, I will repeat the dose."

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action? 1.Weighing the diapers 2.Monitoring the intake closely 3.Comparing the intake with the output 4.Asking the primary health care provider for permission to insert a Foley catheter

Weighing the diapers

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child? 1."Has the child been vomiting?" 2."Has the child had any diarrhea?" 3."Does the child complain of chest pain?" 4."Has the child complained of a sore throat within the past few months?"

"Has the child complained of a sore throat within the past few months?"

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1."Has the child complained of back pain?" 2."Has the child complained of headaches?" 3."Has the child had any nausea or vomiting?" 4."Has the child had a sore throat or a fever within the past 2 months?"

"Has the child had a sore throat or a fever within the past 2 months?"

A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder? 1."The infant has a single vessel that overrides both ventricles of the heart." 2."This disorder causes frequent episodes of hypercyanotic spells." 3."The disorder means there is no communication from the right atrium to the right ventricle of the heart." 4."The disorder means there is no communication from the systemic and pulmonary circulations of the heart."

"The disorder means there is no communication from the right atrium to the right ventricle of the heart."

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1.Bradypnea 2.Diaphoresis 3.Decreased blood pressure (BP) 4.A weight gain of 1 lb in 1 day

A weight gain of 1 lb in 1 day

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis? 1.Chest x-ray 2.Blood cultures 3.Echocardiogram 4.Transesophageal echocardiography

Blood cultures

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure? 1.Assess for any bleeding on the dressing. 2.Position the child's leg so that it is straight. 3.Assess the strength and presence of the distal pulses. 4.Take the vital signs including blood pressure and oxygen saturation.

Assess for any bleeding on the dressing.

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF? 1.Immunoglobulin 2.Red blood cell count 3.Antistreptolysin O titer 4.White blood cell count

Antistreptolysin O titer

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply. 1.Our child will eventually grow out of this condition. 2.It is likely our child will suffer from a failure to thrive. 3.It is not necessary to avoid individuals with the common cold. 4.It is vital that we keep track of how much our baby eats and any episodes of diarrhea. 5.When our baby has difficulty breathing and turns blue, we should hold the baby in the knee-chest position.

Our child will eventually grow out of this condition. It is not necessary to avoid individuals with the common cold.

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition? 1.Peripheral hypoxia 2.Chronic hypertension 3.Delayed physical growth 4.Destruction of bone marrow

Peripheral hypoxia

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take? 1.Call a code. 2.Place the infant in a prone position. 3.Place the infant in a knee-chest position. 4.Contact the respiratory therapy department.

Place the infant in a knee-chest position.

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child? 1.When the child is sleeping 2.When changing the child's diapers 3.When the mother is holding the child 4.When drawing blood for electrolyte levels

When drawing blood for electrolyte levels

The nurse is preparing to administer digoxin to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action? 1.Withhold the medication. 2.Administer the medication. 3.Double-check the apical heart rate and administer the medication. 4.Check the blood pressure and respirations and administer the medication

Withhold the medication.

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1."A balance of rest and exercise is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after this surgery."

"I can apply lotion or powder to the incision if it is itchy."

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply. 1."I am concerned this client has Kawasaki's disease. Can you please come assess this client?" 2."This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." 3."It is most likely Kawasaki disease because it is the leading cause of acquired cardiovascular disease in the U.S." 4."I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." 5."I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

"I am concerned this client has Kawasaki's disease. Can you please come assess this client?" "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1."I know that my child will outgrow this problem, just give him time." 2."I know that I need to be alert for signs of heart failure with this defect until it is repaired." 3."The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4."As I understand it, my child may have to have his defect closed, either during a catheterization or by surgery."

"I know that my child will outgrow this problem, just give him time."

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply. 1.Cough 2.Irritability 3.Scalp diaphoresis 4.Tachypnea, tachycardia 5.Slow and shallow breathing

Irritability Scalp diaphoresis Tachypnea, tachycardia

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1.Cracked lips 2.A normal appearance 3.Conjunctival hyperemia 4.Desquamation of the skin

Conjunctival hyperemia

The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid is prescribed for the child. Which nursing action is appropriate? 1.Consult with the registered nurse to verify the prescription. 2.Administer the acetylsalicylic acid if the child's temperature is elevated. 3.Administer the acetylsalicylic acid if the child experiences any joint pain. 4.Administer acetaminophen instead of the acetylsalicylic acid for temperature elevation.

Consult with the registered nurse to verify the prescription.

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms? 1.Increased in the arms and the legs 2.Decreased in the arms and the legs 3.Decreased in the legs and increased in the arms 4.Increased in the legs and decreased in the arms

Decreased in the legs and increased in the arms

The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)? 1.Pallor 2.Strong sucking reflex 3.Slow and shallow breathing 4.Diaphoresis during feeding

Diaphoresis during feeding

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1.Pallor 2.Hyperactivity 3.Exercise intolerance 4.Gastrointestinal disturbances

Exercise intolerance

The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs? 1.Bleeding 2.Failure to thrive 3.Heart failure (HF) 4.Decreased tolerance to stimulation

Heart failure (HF)

The nurse is reviewing a primary health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan? 1.Digoxin 2.Heparin infusion 3.Morphine sulfate 4.Immune globulin

Immune globulin

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease? 1.It is an acquired cell-mediated immunodeficiency disorder. 2.It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. 3.It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. 4.It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first? 1.Assist to administer morphine sulfate 2.Place the child in a knee-chest position. 3.Administer 100% oxygen by face mask. 4.Prepare to administer intravenous fluids.

Place the child in a knee-chest position.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The parent of the child asks the nurse why the child needs the medication. The nurse correctly responds that the purpose of this medication is which explanation? 1.Maintains an adequate hormone level 2.Prevents hypercyanotic (blue or tet) spells 3.Maintains the position of the great arteries 4.Provides adequate oxygen saturation and maintains cardiac output

Provides adequate oxygen saturation and maintains cardiac output