NCLEX Review Pediatric Cardiovascular w/ Rationale

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

4. "Has the child complained of a sore throat within the past few months?" Rationale: Rheumatic fever (RF) characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child or any family members have had a sore throat or unexplained fever within the past 2 months. The remaining options are unrelated to RF.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The parent of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the parent about the action of the medication? 1. Prevents blue (tet) spells 2. Maintains adequate cardiac output 3. Maintains an adequate hormonal level 4. Maintains the position of the great arteries

2. Maintains adequate cardiac output Rationale:A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing is inadequate to maintain adequate cardiac output. The remaining options are incorrect. In addition, tet spells occur in tetralogy of Fallot, not in transposition of the great arteries. Prostaglandin E1 does not affect hormone levels, nor does it affect the position of the arteries.

The nurse is caring for an infant client with tetralogy of Fallot who is experiencing a hypercyanotic spell. Place the actions the nurse would take in order of priority. All options must be used. 1. Administer 100% oxygen. 2. Place the infant in a knee-chest position. 3. Administer morphine sulfate as prescribed. 4. Document the occurrence, actions taken, and the infant's response. 5. Administer fluids intravenously.

(2) 1. Administer 100% oxygen. (1) 2. Place the infant in a knee-chest position. (3) 3. Administer morphine sulfate as prescribed. (5) 4. Document the occurrence, actions taken, and the infant's response. (4) 5. Administer fluids intravenously. Rationale: Hypercyanotic spells are also known as tet spells or blue spells and occur in infants or children with certain types of heart defects. The infant or child becomes acutely cyanotic and hyperpneic because of the sudden infundibular spasm. These spells may occur as a result of stressful procedures or from feeding, crying, or defecation. If a spell occurs, the nurse needs to provide a calm and comforting approach while immediately placing the infant in the knee-chest position; this assists breathing and increases oxygenation to body tissues. Oxygen is administered by face mask or blow-by. Morphine sulfate is administered as prescribed subcutaneously or through an existing intravenous line (morphine sulfate helps to reduce the infundibular spasm). Intravenous fluids are administered to replace fluids and to keep the infant well hydrated and to keep the hematocrit and blood viscosity within acceptable limits. Depending on the infant's response, a repeated dose of morphine sulfate may be prescribed. Finally, the nurse documents the occurrence, actions taken, and the infant's response.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1. Prone position 2. Knee-chest position 3. High-Fowler's position 4. Reverse Trendelenburg's position

2. Knee-chest position Rationale: Tetralogy of Fallot includes four defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to right. If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. All other options will not improve systemic arterial oxygen saturation.

The nurse is caring for a child diagnosed with Kawasaki disease who has been experiencing a fever. Which other clinical manifestations would the nurse expect if this diagnosis is accurate? Select all that apply. 1. Koplik spots 2. Strawberry tongue 3. Bilateral conjunctival erythema 4. Two cervical lymph nodes measuring 2 centimeters 5. Erythema and peeling of the palms and soles of the feet

2. Strawberry tongue 3. Bilateral conjunctival erythema 4. Two cervical lymph nodes measuring 2 centimeters 5. Erythema and peeling of the palms and soles of the feet Rationale:In addition to a fever for more than 5 days, four of the five following clinical criteria must be present in order for Kawasaki disease to be a potential diagnosis: changes in the extremities, including edema that can progress to skin peeling of the palms and soles of the feet; bilateral conjunctival erythema; changes in the oral mucous membranes, including strawberry tongue; a polymorphous rash; or cervical lymphadenopathy in which at least one cervical lymph node is larger than 1.5 centimeters. Koplik spots are not a diagnostic criterion for Kawasaki disease and are associated with measles. Therefore, options 2, 3, 4 and 5 are correct.

The nurse is providing discharge teaching to the parents of a child who has recovered from Kawasaki disease. The child received intravenous immunoglobulin (IVIG) and aspirin as part of the treatment plan. Which statement from the parents would indicate a need for further teaching? 1. "We can give warm baths to help with any joint pain." 2. "We need to take the temperature daily for the next week or two." 3. "We will still plan for my child to receive the MMR vaccine at the doctor's appointment in 2 weeks." 4. "If the skin on my child's hands and feet begins to peel, this is normal and does not need to be reported to the doctor."

3. "We will still plan for my child to receive the MMR vaccine at the doctor's appointment in 2 weeks." Rationale: Kawasaki disease is an acute systemic disease of unknown cause. It results in widespread vasculitis that can have profound effects on the heart, including heart failure, myocarditis, coronary artery dilatation, and coronary artery aneurysm. The disease is usually self-limiting with minimal long-term complications. Joint pain and skin peeling of the hands and feet are expected findings during recovery. The client's temperature needs to be taken for the first week or two weeks after recovery to monitor for a fever, which needs to be reported to the physician. The administration of live vaccines, including measles, mumps, rubella (MMR), and varicella, needs to be deferred for 11 months after the administration of IVIG, as IVIG can diminish the body's ability to produce antibodies and diminish vaccine efficacy. Therefore, option 3 is the statement that prompts a need for further teaching, as the MMR vaccine needs to be deferred for at least 11 months after the administration of IVIG.

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1. Anxiety 2. A temper tantrum 3. A hypercyanotic episode 4. The need for immediate primary health care provider notification

3. A hypercyanotic episode Rationale: Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate primary health care provider (PHCP) notification is not required unless other appropriate nursing interventions are unsuccessful. Anxiety and a temper tantrum are unrelated to tetralogy of Fallot.

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the primary health care provider.

3. Administer the medication. Rationale: The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min. Because the apical rate is normal, the remaining options are incorrect.

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse would expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher-than-normal body weight

3. Bluish discoloration of the skin Rationale: The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Option 1, severe bradycardia, and option 2, asymptomatic after feeding, are inaccurate. Many children with a left-to-right shunt remain asymptomatic. High body weight is incorrect because these children usually have lower-than-normal body weight.

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Check the blood pressure and then administer the medication. 4. Check the respiratory rate and then administer the medication.

3. Check the blood pressure and then administer the medication. Rationale: Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity, and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (0.5 to 0.8 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. The apical pulse rate for an infant is 90 to 110 beats/min. If the heart rate is less than 90 beats/minute in an infant, the nurse would withhold the dose and contact the primary health care provider. Therefore, the remaining options are incorrect actions; it would be harmful to administer the medication.

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

3. Diaphoresis during feeding Rationale: The early symptoms of heart failure (HF) include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.

The nurse is caring for a 4-year-old child diagnosed with Kawasaki disease. The nurse notices that the child's urinary output is decreasing, the child's heart rate has increased from a baseline of 90 beats per minute at rest to 130 beats per minute at rest, and a new gallop is noted on cardiac auscultation. Which complication would the nurse suspect? 1. Pneumonia 2. Myocarditis 3. Heart failure 4. Coronary artery dilatation

3. Heart failure Rationale: Kawasaki disease is an acute systemic disease of unknown cause that results in widespread vasculitis. The disease has profound effects on the cardiovascular system and can cause myocarditis, heart failure, the dilatation of coronary arteries, and coronary artery aneurysms. Heart failure causes decreased cardiac output and subsequent decreased renal perfusion, which results in decreased urinary output, fluid retention, and weight gain. A cardiac gallop can also develop in the setting of heart failure. Also, tachycardia may be noted. A normal heart rate for a child of this age is 80 to 120 beats per minute. Therefore, a heart rate of 130 beats per minute is elevated and indicates tachycardia. Due to the decrease in urinary output, the tachycardia, and the presence of a gallop, heart failure would be suspected in this child. Therefore, option 3 is correct.

The nurse is caring for a child diagnosed with Kawasaki disease. Keeping the pathophysiology in mind, the nurse carefully monitors the child for which complication? 1. Fever 2. Paralytic ileus 3. Myocardial infarction 4. Arthralgic joint involvement

3. Myocardial infarction Rationale: Kawasaki disease is an acute systemic disease of unknown cause that results in widespread vasculitis. The cardiovascular system is affected by the disease, and heart failure, coronary artery dilatation, and coronary artery aneurysms can develop. The development of a large coronary artery aneurysm can result in myocardial ischemia and subsequent myocardial infarction related to a coronary artery thrombosis or the development of coronary artery stenosis as the vessel heals. Fever is an expected symptom of Kawasaki disease. Paralytic ileus is not a complication of this disease, and most complications are cardiovascular in nature. The child may experience joint pain and swelling, a condition that resolves on its own. Therefore, option 3 is correct.

The parent of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the parent? 1. "The child may return to school in 1 week." 2. "The child will not be able to return to school during this academic year." 3. "The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."

4. "The child may return to school in 3 weeks but needs to go half-days for the first few days." Rationale: After heart surgery, the child may be able to return to school in 3 weeks but needs to go half-days for the first few days. The parent also needs to be told that that the child cannot participate in physical education for 2 months. The remaining options are incorrect.

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the primary health care provider? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb (0.5 kg) in 1 day

4. A weight gain of 1 lb (0.5 kg) in 1 day Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 1 lb (0.5 kg) in 1 day is caused by the accumulation of fluid. The nurse would assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the primary health care provider. Tachypnea and increased blood pressure occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and usually occurs with exertional activities.

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia? 1. Tachypnea 2. Tachycardia 3. Sucking on the fingers 4. Clubbing of the fingers

4. Clubbing of the fingers Rationale: The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Tachypnea and tachycardia are signs of acute hypoxia. Sucking on the fingers may indicate hunger or irritability. Further assessment is needed to determine whether this behavior is due to congenital heart disease.

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 aspirin is prescribed for the child. Which nursing action is most appropriate? 1. Administer acetaminophen for temperature elevation. 2. Administer the aspirin if the child's temperature is elevated. 3. Administer the aspirin if the child experiences any joint pain. 4. Consult with the primary health care provider to verify the prescription.

4. Consult with the primary health care provider to verify the prescription. Rationale: Anti-inflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin would not be given to a child who has chickenpox or other viral infections because of the risk of Reye's syndrome. Therefore, the nurse would consult with the primary health care provider (PHCP) to verify the prescription. The nurse would not administer acetaminophen without specific PHCP prescriptions. Administering aspirin is not an appropriate action without consulting the PHCP first.

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1. Absence of C-reactive protein 2. Presence of Reed-Sternberg cells 3. Decreased antistreptolysin O titer 4. Elevated erythrocyte sedimentation rate

4. Elevated erythrocyte sedimentation rate Rationale: Rheumatic fever develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

The nurse is assigned to care for an infant with tetralogy of Fallot. The parent 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. What is the priority action by the nurse? 1. Notify the nursing supervisor. 2. Contact the respiratory therapist. 3. Place the infant in a prone position. 4. Place the infant in a knee-chest position.

4. Place the infant in a knee-chest position. Rationale: If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore, the remaining options are not the best initial or priority actions.

A primary health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation would the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the parent is holding the infant 4. When drawing blood for electrolyte level testing

4. When drawing blood for electrolyte level testing Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are unlikely to produce crying in the infant.

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The parent also tells the nurse that the newborn just vomited formula. Which intervention would the nurse take? 1. Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the primary health care provider.

4. Withhold the medication and notify the primary health care provider. Rationale: The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the primary health care provider. Retaking the apical pulse is not indicated given the context of the other findings in this question. Administering the medication could potentially cause harm. Withholding the medication for 1 hour does not address the problem of toxicity.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 3. Presence of Reed-Sternberg cells 4. Presence of group A beta-hemolytic strep 5. Decreased erythrocyte sedimentation rate

1. Elevated C-reactive protein 2. Elevated antistreptolysin O titer 4. Presence of group A beta-hemolytic strep Rationale: Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1. Elevated antistreptolysin O titer 2. Decreased erythrocyte sedimentation rate 3. Negative result on antinuclear antibody assay 4Negative result on C-reactive protein determination

1. Elevated antistreptolysin O titer Rationale: In the presence of rheumatic fever, the child will exhibit an elevated antistreptolysin O titer, an elevated erythrocyte sedimentation rate, leukocytosis, and a positive result on C-reactive protein determination. A positive result on antinuclear antibody testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and also will be positive with rheumatic fever.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse would include monitoring the child for signs of which condition? 1. Bleeding 2. Heart failure 3. Failure to thrive 4. Decreased tolerance to stimulation

2. Heart failure Rationale: Nursing care initially centers on observing for signs of heart failure. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distention. The remaining options are not conditions directly associated with this disorder.

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the parent. Which statement by the parent indicates a need for further teaching? 1. "Quiet activities are allowed." 2. "The child should play inside for now." 3. "Visitors are not allowed for 1 month." 4. "The regular schedule for naps is resumed."

3. "Visitors are not allowed for 1 month." Rationale: Visitors without signs of any infection are allowed to visit the child. The parent would be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge. The remaining options are accurate instructions regarding activity following heart surgery.

The clinic nurse reviews the record of a child just seen by a primary health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Exercise intolerance Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted but is not specific to this type of disorder alone. Options 2 and 4 are unrelated to this disorder.