PEDS Prep U Chapter 19: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

A group of nurses is reviewing the cardiovascular system and its function. Which statement by one of the nurses demonstrates an understanding of a child's cardiovascular system?

"At birth, the infant's right and left ventricle are about the same size." Explanation: At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size of the heart is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult's heart

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

"Children who have this diagnosis may have had strep throat." Explanation: Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle

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." Explanation: Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child. Questioning the parents as to whether they are making nutritious foods or foods preferred by the child does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.

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." Explanation: Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should assess the head pain and the child's fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. The report of itching on the child's chest should be evaluated and reported to the health care provider but does not necessarily warrant cancellation of the procedure unless determined that it is a sign of a viral infection.

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." 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 parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best?

"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." Explanation: Clubbing (which is what the parents are describing) of fingertips or toes can occur from the chronic hypoxia that occurs with disorders with decreased pulmonary blood flow, such as tricuspid atresia. Using the term "low oxygen levels in the blood" rather than "chronic hypoxia" is a better way to explain to the parents what is happening with their child. Clubbing is not the result of increased cardiac workload. Red blood cell pooling is not the cause of clubbing. Although clubbing is a possible result of tricuspid atresia, telling the parents this is a "common complication" does not address the parent's concerns.

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." Explanation: For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

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. Treating the cause of the disease will help" best answers the question while also showing empathy.

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. "Our child will be so excited to get back to soccer league in a few days." "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." "It's wonderful that our child will never have an abnormal heart rhythm again." "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."

-"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 health care provider and other health team members are discussing congenital heart disorders that increase pulmonary blood flow. Which disorders are topics for this discussion? Select all that apply. Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Pulmonary stenosis Coarctation of the aorta

-Ventricular septal defect -Patent ductus arteriosus -Atrioventricular canal defect

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 Explanation: A newborn whose oxygenation is not improving with oxygen warrants immediate attention. Congenital heart disease needs to be suspected in the cyanotic newborn who does not improve with oxygen administration. In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. This is an abnormal assessment finding that warrants follow-up but does not warrant immediate action. Clubbing is also an abnormal finding and warrants follow-up but not immediate action. It implies chronic hypoxia due to severe congenital heart disease. A temporal temperature of 101°F (38.3°C) is an abnormal assessment finding and warrants follow-up but not immediate action. Fever would suggest a possible infection.

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 conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever?a. Polyarthritisb. Osler nodesc. Janeway spotsd. Splinter hemorrhages of distal third of nails

ANS A:Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis.

Which should the nurse consider when preparing a school-age child and the family for heart surgery?a. Unfamiliar equipment should not be shown.b. Let child hear the sounds of an ECG monitor.c. Avoid mentioning postoperative discomfort and interventions.d. Explain that an endotracheal tube will not be needed if the surgery goes well.

ANS B:The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.

Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.) a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge.

ANS C, FRationale: The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion. The child should have a patent peripheral intravenous line (PIV) to ensure adequate hydration. The child should remain on bed rest with the leg extended for a minimum of 4 hours. Initially vital signs are taken every 15 minutes, with emphasis on a heart rate counted for 1 minute. Pulses above the catheterization site should not be affected by the catheterization. Pulses distal to the site should be monitored. The pressure dressings should not be removed for 24 hours.

Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.) a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time

ANS C,D,FRATIONALE: Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. Thirst, diminished urinary output, irritability, apprehension, normal blood pressure, and narrowing pulse pressure are signs of compensated shock.

When discussing hyperlipidemia with a group of adolescents, the nurse should explain that cardiovascular disease can be prevented by high levels of:a. cholesterol.b. triglycerides.c. low-density lipoproteins (LDLs).d. high-density lipoproteins (HDLs).

ANS D:HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs are not protective against cardiovascular disease.

Jos is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be:a. directed at his parents because he is too young to understand.b. detailed in regard to the actual procedures so he will know what to expect.c. done several days before the procedure so that he will be prepared.d. adapted to his level of development so that he can understand.

ANS D:Preoperative teaching should always be directed at the childs stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.

The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?a. Cardiac arrhythmiab. Hypostatic pneumoniac. Heart failured. Rapidly increasing blood pressure

ANS: ABecause a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.

A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse be administering?a. Captopril (Capoten)b. Furosemide (Lasix)c. Spironolactone (Aldactone)d. Chlorothiazide (Diuril)

ANS: ACaptopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules.

The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?a. It decreases edema.b. It decreases cardiac output.c. It increases heart size.d. It increases venous pressure.

ANS: ADigoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size and venous pressure are decreased by digoxin.

Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis?a. Osler nodesb. Janeway lesionsc. Subcutaneous nodulesd. Aschoff nodes

ANS: AOsler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.

The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophyb. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophyd. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

ANS: ATetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.

Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurses reply should be based on which statement? a. Child needs opportunities to play with peers.b. Child needs to understand that peers activities are too strenuous. c. Parents can meet all of the childs needs.d. Constant parental supervision is needed to avoid overexertion.

ANS: AThe child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. The child will be able to regulate activities.

The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement?a. Administering penicillinb. Avoiding salicylates (aspirin)c. Imposing strict bed rest for 4 to 6 weeksd. Administering corticosteroids if chorea develops

ANS: AThe goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment.

The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands?a. Organize nursing activities to allow for uninterrupted sleep.b. Allow the infant to sleep through feedings during the night.c. Wait for the infant to cry to show definite signs of hunger.d. Discourage parents from rocking the infant

ANS: AThe infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infants sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful.

The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct?a. You may need to increase the caloric density of your infants formula.b. You should feed your baby every 2 hours.c. You may need to increase the amount of formula your infant eats with each feeding.d. You should place a nasal oxygen cannula on your infant during and after each feeding.

ANS: AThe metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings.

The nurse is teaching nursing students about shock that occurs in children. One of the most frequent causes of hypovolemic shock in children is:a. sepsis.b. blood loss.c. anaphylaxis.d. congenital heart disease.

ANS: BBlood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease contributes to hypervolemia, not hypovolemia.

As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in:a. chlorides.b. potassium.c. sodium.d. vitamins.

ANS: BDiuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The childs diet should be supplemented with this electrolyte. With this type of diuretic, potassium must be monitored and supplemented as needed.

An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.a. 60b. 70c. 90d. 100

ANS: BIf a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld; 60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110 beats/min is the determination for not giving a digoxin dose to infants and young children.

The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?a. Minimize seizures.b. Prevent dehydration.c. Promote cardiac output.d. Reduce energy expenditure.

ANS: BIn children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.

Which occurs in septic shock?a. Hypothermiab. Increased cardiac outputc. Vasoconstrictiond. Angioneurotic edema

ANS: BIncreased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common than vasoconstriction. Angioneurotic edema occurs as a manifestation in anaphylactic shock.

A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?a. Atrial septal defectb. Tetralogy of Fallotc. Ventricular septal defectd. Patent ductus arteriosus

ANS: BTetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.

The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?a. I should avoid tub baths but may shower.b. I have to stay on strict bed rest for 3 days.c. I should remove the pressure dressing the day after the procedure.d. I may attend school but should avoid exercise for several days.

ANS: BThe child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school.

An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurses first action should be to:a. assess for neurologic defects.b. place the child in the knee-chest position.c. begin cardiopulmonary resuscitation.d. prepare family for imminent death.

ANS: BThe first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.

The primary nursing intervention to prevent bacterial endocarditis is to:a. institute measures to prevent dental procedures.b. counsel parents of high-risk children about prophylactic antibiotics.c. observe children for complications, such as embolism and heart failure.d. encourage restricted mobility in susceptible children

ANS: BThe objective of nursing care is to counsel the parents of high-risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The childs dentist should be aware of the childs cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Children should be observed for complications such as embolism and heart failure and restricted mobility should be encouraged in susceptible children, but maintaining good oral health and prophylactic antibiotics is important.

Which is the leading cause of death after heart transplantation?a. Infectionb. Rejectionc. Cardiomyopathyd. Heart failure

ANS: BThe posttransplant course is complex. The leading cause of death after cardiac transplantation is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Heart failure is not a leading cause of death.

The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity?a. Seizuresb. Vomitingc. Bradypnead. Tachycardia

ANS: BVomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. The heart rate will be slower, not faster.

A chest radiograph film is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the radiograph show about the heart? The nurses response should be based on knowledge that the x-ray film will show:a. bones of chest but not the heart.b. measurement of electrical potential generated from heart muscle. c. permanent record of heart size and configuration.d. computerized image of heart vessels and tissues.

ANS: CA chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It will provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs. Electrocardiography (ECG) measures the electrical potential generated from heart muscle. Echocardiography will produce a computerized image of the heart vessels and tissues by using sound waves.

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?a. Diphenhydramine (Benadryl)b. Dobutamine (Dobutarex)c. Epinephrine (Adrenalin)d. Calcium chloride (calcium chloride)

ANS: CAfter the first priority of establishing an airway, administration of epinephrine is the drug of choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions. Dobutamine and calcium chloride are not appropriate drugs for this type of reaction.

A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response?a. You will be able to hold your child during the procedure.b. Your child can be active during the procedure, but cant sit in your lap.c. Your child must lie quietly; sometimes a mild sedative is administered before the procedure.d. The procedure is invasive so your child will be restrained during the echocardiogram.

ANS: CAlthough an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychological preparation for the test. The distraction of a video or movie is often helpful.

Which defect results in increased pulmonary blood flow?a. Pulmonic stenosisb. Tricuspid atresiac. Atrial septal defectd. Transposition of the great arteries

ANS: CAtrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

The nurse is caring for a child after heart surgery. Which should the nurse do if evidence is found of cardiac tamponade?a. Increase analgesia.b. Apply warming blankets.c. Immediately report this to physician.d. Encourage child to cough, turn, and breathe deeply.

ANS: CIf evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space constricting the heart, the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred till after the evaluation by the physician.

Which is an important nursing consideration when suctioning a young child who has had heart surgery?a. Perform suctioning at least every hour.b. Suction for no longer than 30 seconds at a time.c. Administer supplemental oxygen before and after suctioning.d. Expect symptoms of respiratory distress when suctioning.

ANS: CIf suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.

A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.a. 60b. 70c. 90 to 110d. 110 to 120

ANS: CIf the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be givento a 6-month-old. 60 beats/min is the cut-off for holding the digoxin dose in an adult. 70beats/min is the determining heart rate to hold a dose of digoxin for an older child. 110 to120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.

Which is an important nursing consideration when chest tubes will be removed from a child?a. Explain that it is not painful.b. Explain that only a Band-Aid will be needed.c. Administer analgesics before procedure.d. Expect bright red drainage for several hours after removal.

ANS: CIt is appropriate to prepare the child for the removal of chest tubes with analgesics. Shortacting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.

Which action by the school nurse is important in the prevention of rheumatic fever?a. Encourage routine cholesterol screenings.b. Conduct routine blood pressure screenings.c. Refer children with sore throats for throat cultures.d. Recommend salicylates instead of acetaminophen for minor discomforts.

ANS: CNurses have a role in preventionprimarily in screening school-age children for sore throats caused by group A b-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A b-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

Clinical manifestations of toxic shock syndrome include:a. severe hypertension.b. subnormal temperature.c. erythematous macular rash.d. papular rash over extremities.

ANS: COne of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9 C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.

Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?a. Tachypneab. Tachycardiac. Peripheral edemad. Pale, cool extremities

ANS: CPeripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.

Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?a. Pulmonary congestionb. Congenital heart defectc. Heart failured. Systemic venous congestion

ANS: CThe definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the bodys metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.

The parents of a young child with heart failure tell the nurse that they are nervous about giving digoxin (Lanoxin). The nurses response should be based on which statement?a. It is a safe, frequently used drug.b. It is difficult to either overmedicate or undermedicate with digoxin. c. Parents lack the expertise necessary to administer digoxin.d. Parents must learn specific, important guidelines for administration of digoxin.

ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Small amounts of the liquid are given to infants, making it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely.

Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?a. Neurogenicb. Cardiogenicc. Hypovolemicd. Anaphylactic

ANS: DAnaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.

Which is a common, serious complication of rheumatic fever?a. Seizuresb. Cardiac arrhythmiasc. Pulmonary hypertensiond. Cardiac valve damage

ANS: DCardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever

Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?a. Thirstb. Irritabilityc. Apprehensiond. Confusion and somnolence

ANS: DConfusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.

When caring for the child with Kawasaki disease, the nurse should know which information?a. A childs fever is usually responsive to antibiotics within 48 hours.b. The principal area of involvement is the joints.c. Aspirin is contraindicated.d. Therapeutic management includes administration of gamma globulin and aspirin.

ANS: DHigh-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of the therapy.

The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is too wet. The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to:a. notify physician.b. apply new bandage with more pressure.c. place the child in Trendelenburg position.d. apply direct pressure above catheterization site.

ANS: DIf bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.

Seventy-two hours after cardiac surgery, a young child has a temperature of 101 F. Which action should the nurse take?a. Keep child warm with blankets.b. Apply a hypothermia blanket.c. Record temperature on nurses notes.d. Report findings to physician.

ANS: DIn the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.

Which is the most common causative agent of bacterial endocarditis?a. Staphylococcus albusb. Streptococcus hemolyticusc. Staphylococcus albicansd. Streptococcus viridans

ANS: DS. viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents.

Which explanation regarding cardiac catheterization is appropriate for a preschool child?a. Postural drainage will be performed every 4 to 6 hours after the test.b. It is necessary to be completely asleep during the test.c. The test is short, usually taking less than 1 hour.d. When the procedure is done, you will have to keep your leg straight for at least 4 hours

ANS: DThe child's leg will have to be maintained in a straight position for approximately 4 hours. Younger children can be held in the parents lap with the leg maintained in the correct position. Postural drainage will not be performed unless the child has corresponding pulmonary problems. The child should be sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time from start to finish.

Surgical closure of the ductus arteriosus would:a. stop the loss of unoxygenated blood to the systemic circulation.b. decrease the edema in legs and feet.c. increase the oxygenation of blood.d. prevent the return of oxygenated blood to the lungs.

ANS: DThe ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs.

A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. Once the airway is established, the nurse should do which action? Place in correct sequence. a. Administer epinephrine. b. Keep the child warm and calm. c. Obtain vascular access.

ANS: c, a, b The correct sequence of actions is to obtain vascular access, administer epinephrine, and then to keep the child warm and calm.

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. Explanation: An infant with decreased pulse strength in the lower extremities may have coarctation of the aorta. Assessing blood pressures in all extremities is most helpful in assisting the nurse with gathering assessment data prior to contacting the health care provider. The nurse does not have enough information to apply oxygen at this time or prepare the newborn for balloon angioplasty

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. Explanation: Total cholesterol levels below 170 mg/dl and LDL levels less than 100 mg/dl are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels between 170 and 199 mg/dl and LDL levels between 100 and 129 mg/dl are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dl and LDL levels greater than or equal to 130 mg/dl are considered elevated and place this child at greatest risk.

The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level?

Digoxin Explanation: The use of large doses of digoxin at the beginning of therapy to build up the blood levels of the drug to a therapeutic level is known as digitalization. During the 24 hours digitalization is occurring, the child should be on a cardiac monitor and the nurse should monitor the PR interval and a decreased ventricular rate. The other listed medications are not administered in this manner. Albuterol is inhaled for asthma treatment and used primarily for exacerbations. Ferrous sulfate is give for iron-deficiency anemia, and spironolactone is a diuretic.

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. Although the neonate has an elevated temperature, administration of acetaminophen does not take priority over breathing. If the neonate continues to show signs of pulmonary overload, the nurse could advise the mother to give expressed breast milk through a bottle or nasogastric tube.

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 RBC Explanation: Polycythemia can occur in clients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

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. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later

The nurse is caring for a 1-day-old newborn with patent ductus arteriosus with the following vital signs: pulse rate 160 bpm, respiratory rate 80 breaths/min, oxygen saturation 92%, retractions, and crackles noted in bilateral lungs. Which nursing action(s) is appropriate at this time? Select all that apply. Assess for cyanosis. Initiate intravenous access. Apply oxygen. Feed the client a high-calorie formula. Begin indomethacin infusion.

Initiate intravenous access. Apply oxygen. Begin indomethacin infusion.

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. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.

A 1-year-old with tetralogy of Fallot turns blue during a temper tantrum. What will the nurse do first?

Place child in the knee-to-chest position. Explanation: Tetralogy of Fallot is a cyanotic heart defect. Hypercyanosis can develop suddenly. The symptoms are increased cyanosis, hypoxemia, dyspnea, and agitation. The nurse should use a calm, comforting approach with the child and place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. This position increases pulmonary blood flow by increasing systemic vascular resistance. The additional interventions for a hypercyanotic spell are to administer oxygen and give morphine, IV fluids, and propranolol. A child will not understand to calm down and cannot be expected to listen during a temper tantrum. Assessing the child's heart rate and respirations are not priority. Perfusion is priority for this client at this time.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Place the infant in the knee-chest position. Explanation: Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

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. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated. Leukopenia, increased platelets, and anemia are not associated with tetralogy of Fallot.

The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.) a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue

Rationale: ANS: C, D, EThe signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

The child will need the blood pressure checked two more times. Explanation: The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.

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. Explanation: Following cardiac repair there is always a possibility of arrhythmias. The wires are placed and connected to an external pacemaker. This is done as a preventive measure and can be used if an arrhythmia occurs. Once it is felt the child is in no danger of an arrhythmia, the wires are removed. There is no set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization

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.

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

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.

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.

A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child?

lower extremities Explanation: Edema of the lower extremities is characteristic of right ventricular heart failure in older children. In infants, peripheral edema occurs first in the face, then the presacral region, and the extremities.

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. Insulin would be given for diabetes and phenytoin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.

The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding?

softening of the nail beds Explanation: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends

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

tetralogy of Fallot Explanation: Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

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. Stomach upset, nausea, and abdominal distress are common with oral antibiotics and do not need to be reported immediately