NUR 243 PrepU ch 19 Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

The parents of a 10-year-old boy bring the child to the clinic for an evaluation. Which statement by the parents would alert the nurse to the possibility of rheumatic fever?

"He had a pretty bad sore throat about 10 days ago." Explanation: Rheumatic fever is an autoimmune disease that occurs as a reaction to a group A beta-hemolytic streptococcal infection, specifically, a pharyngitis. Inflammation from the immune response leads to inflammatory lesions in the heart, blood vessels, brain, and joints. A child with rheumatic fever typically has a higher fever than that reported by the parents in this scenario. A macular rash (not a white thick coating of the tongue) found predominantly on the trunk is an infrequent symptom but if seen is a virtually definitive sign of rheumatic fever.

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." Explanation: Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond?

"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain."

The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply.

"We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed."

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings?

"Your daughter has an innocent heart murmur, which is nothing to worry about." Explanation: The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur

The nurse is caring for children at a local hospital. Which child warrants immediate attention from the nurse?

1-week-old newborn whose oxygenation is not improving with oxygen

The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy?

100 to 120/70 to 80 mm Hg

The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply.

16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse

Which nursing diagnosis would best apply to a child with rheumatic fever?

Activity intolerance related to inability of heart to sustain extra workload Explanation: Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness.

A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant?

Administer oxygen. Explanation: If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding.

The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate?

Apply pressure 1 inch above the site. Explanation: If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours.

The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first?

Assess blood pressure in all extremities.

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition?

Assessing for the presence of femoral pulses Explanation: Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection?

Avoid drawing a blood specimen from the right femoral vein before the procedure

What information would be included in the care plan of an infant in heart failure?

Begin formulas with increased calories. Explanation: Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation.

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease?

Breastfeed with small, frequent feeds. Explanation: Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily.

The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl.

A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent?

Have the child be seen by the primary care provider. Explanation: Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever.

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

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority?

Initiate intravenous access. Explanation: A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention?

Notify the doctor immediately. Explanation: The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position. Explanation: The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover?

Polycythemia Explanation: Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia Explanation: Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?

Taking pedal pulses for the first 4 hours Explanation: Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

The nurse is caring for a hospitalized infant with a diagnosis of tetralogy of Fallot, awaiting surgical intervention. Which assessment finding would the nurse expect?

The child has periods of cyanosis and decreased pulse oximetry readings. Explanation: Tetralogy of Fallot is a congenital cardiac disorder resulting in poorly oxygenated blood being perfused. The child will likely have corrective surgery within the first year of life.

The child has returned to the nurse's unit following a cardiac catheterization. The insertion site is located at the right groin. Peripheral pulses were easily palpated in bilateral lower extremities prior to the procedure. Which finding should be reported to the child's physician? Select all that apply.

The child's right foot is cool with a pulse assessed only with the use of a Doppler. The child has a temperature of 102.4° F (39.1° C). The child is reporting nausea.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding?

The liver size increases in right-sided heart failure. Explanation: The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information.

The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. What would be included in the intervention strategies?

The nurse would review the child's 24-hour diet recall

A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse?

These wires are connected to the heart and will detect if your infant's heart gets out of rhythm.

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age. Explanation: A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

This test will check how blood is flowing through the heart.

The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention?

accentuated third heart sound Explanation: An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure; cool, clammy, and pale extremities; and a heart murmur are all associated with cardiovascular disorders. However, these findings do not specifically indicate sudden ventricular distention.

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of:

femoral pulse weaker than brachial pulse. Explanation: A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. -Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. -A narrow or thread pulse is associated with heart failure or severe aortic stenosis. -Hepatomegaly is a sign of right-sided heart failure.

A nurse is providing care to a preterm infant who has been diagnosed with patent ductus arteriosus (PDA) and developed heart failure. Which medication would the nurse expect the health care provider to prescribe to promote closure of the ductus?

indomethacin Explanation: Although digoxin, furosemide, and losartan may be used to treat congestive heart failure, they would have no effect on closing the ductus. For premature infants with heart failure due to a PDA, indomethacin, a nonsteroidal anti-inflammatory and prostaglandin inhibitor, can be utilized to facilitate closure. This is usually given in three separate IV doses

The nurse admits a 10-year-old child who reports a recent onset of heart palpitations and dizziness. Based on the assessment (above), which intervention will the nurse anticipate?

instructing the child to cough forcefully Explanation: The child is exhibiting signs of supraventricular tachycardia (SVT), based on a heart rate of greater than 160 beats/min in a child. Noninvasive treatment can be tried first by encouraging the child to perform a vagal maneuver such as blowing through a pinched straw, bearing down as with a bowel movement, coughing, or gagging.

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 potassium level

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?

tetralogy of Fallot

When educating the family of an infant with a small, asymptomatic atrial septal defect (ASD), what information would be included in the education?

"Most infants do not need surgical repair for this."

A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction?

"My child cannot have any thing to eat or drink after midnight the day of the test." Explanation: Ambulatory electrocardiographic monitoring (Holter) testing is an exam that spans approximately 24 hours. The test is done to review the activity of the heart. The child is encouraged to follow one's normal activities during the test. There is no need for the child to be NPO prior to or during the test.

A nurse is taking the history of a 4-year-old child who will undergo a cardiac catheterization. Which statement by the parent may necessitate rescheduling of the procedure?

"My child seems listless and slightly warm."

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse?

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." Explanation: For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential. Although oxygen must be ordered by the physician and it isn't the best treatment, the nurse stating, "While it seems that oxygen would help, it actually makes the condition worse.

A nurse is preparing to administer a prescribed dose of digoxin to an 6-month-old infant. After assessing the infant's apical pulse, the nurse decides to withhold the dose and notify the health care provider. The nurse bases this decision on which apical pulse rate?

80 beats/min Explanation: Prior to administering each dose of digoxin, the nurse would count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The nurse would withhold the dose and notify the health care provider if the apical pulse is less than 60 in an adolescent, less than 90 in an infant.

The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding?

90/64 mm Hg Explanation: -The toddler or preschool-age child's blood pressure averages 80 to 100/64 mm Hg. -The normal infant's blood pressure is about 80/40 mm Hg. -The school-age child's blood pressure averages 94 to 112/56 mm Hg. -An adolescent's blood pressure averages 100 to 120/50 to 70 mm Hg.

While assessing a neonate with a ventricular septal defect (VSD), the nurse notes crackles and retractions. The nurse obtains the following vital signs: temp 100.2°F (38°C), pulse 134 bpm, respirations 64 breaths/minute, oxygen saturation 97% on room air. What will the nurse do first?

Give furosemide intravenously. Explanation: The nurse's first action when a neonate with a cardiac disorder is experiencing signs of fluid overload but has a normal oxygen saturation is to administer a diuretic such as furosemide. Oxygen could be applied if the furosemide was not effective in reducing fluid overload or if the oxygen saturation was low. This will remove fluid from the lungs, allowing the infant to breathe more easily.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

Peeling hands and feet; fever Explanation: Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot?

altered cardiopulmonary tissue perfusion risk Explanation: Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and parental anxiety will be performed after ensuring cardiopulmonary tissue perfusion is adequate.

A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note?

bounding pulse

The nurse is 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?

esponse: "The feeling of the heart skipping a beat is common." Explanation: Reports of heart "fluttering" or "skipping a beat" should be reported to the doctor as this can be a sign of a complication. The tub bath statement is appropriate because tub baths should be avoided for about 3 days. The strenuous activity statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported.

The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder?

heart failure Explanation: Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. -Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. -Abdominal pain, joint pain, fever, and irritability are signs of Kawasaki disease.

The health care provider suspects an infant may have a ventricular septal defect. The parents ask the nurse what diagnostic tests the infant will need to have to determine this diagnosis. For what test(s) should the nurse provide education to the family? Select all that apply.

magnetic resonance imaging (MRI) echocardiogram cardiac catheterization

A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers?

nonsterioidal anti-inflammatory drugs (NSAIDs) Explanation: Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids.

What would be the most important measure to implement for an infant who develops heart failure?

placing the infant in a semi-Fowler position Explanation: Placing an infant with heart failure in a semi-Fowler position reduces the pressure of the abdominal contents against the chest and allows for better lung expansion

A nurse is reading a journal article about congenital heart conditions that are associated with decreased pulmonary blood flow. The nurse demonstrates understanding of the information when she identifies which anomalies as being associated with tetralogy of Fallot? Select all that apply.

pulmonary stenosis overriding aorta right ventricular hypertrophy

After a cardiac catheterization, the nurse monitors the child's fluid balance closely based on the understanding that:

the contrast material used has a diuretic effect. Explanation: The contrast material has a diuretic effect so the nurse assesses the child closely for signs and symptoms of dehydration and hypovolemia.

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?

wheezing Explanation: The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis.