Archer Child Health - Cardio/Respiratory

The NICU nurse is caring for an infant with heart failure and watching for interventions that necessitate administering oxygen. Of the following procedures, which will the nurse most likely need oxygen to be available? A. Administering vaccinations B. During the infant's naps C. While the infant nurses D. After the parents have held the baby Submit Answer

Explanation Choice A is correct. The nurse would be most accurate if they applied oxygen to the infant receiving vaccinations. Since injections are often painful, most babies cry while receiving them. Crying uses much of an infant's energy, increasing its demand for oxygen. Choices B, C, and D are incorrect. Since napping, nursing, and being held are generally calming moments for an infant, there will likely not be an increased need for oxygen. NCSBN client need Topic: Physiological Integrity, reduction of risk potential Last Updated - 01, Feb 2022

The nurse is caring for a 16-year-old client with cystic fibrosis. The client develops a temperature of 101.2 degrees F (38.4C). Which medication does the nurse administer with top priority? A. IV antibiotic B. Pancreatic enzyme C. Fat soluble vitamin D. Albuterol Submit Answer

Explanation Choice A is correct. Administering the IV antibiotic is the top priority in a client with cystic fibrosis (CF) that develops a fever. Due to the excessively thick mucus that builds up in their bronchi and bronchioles, children with CF are incredibly susceptible to respiratory infections. A fever is an indication of infection and aggressive management is the top priority. Choice B is incorrect. Pancreatic enzymes are administered to children with CF within 30 minutes of any meal and snack. These are given to aid in digestion since the excessive, sticky mucus clogs up the pancreatic duct in these clients. This is a standard medication given every day, but is not the top priority when a child with CF develops a fever. Choice C is incorrect. Fat soluble vitamins are a daily medication for children with CF. Due to the buildup of excessive, sticky mucus in their bile duct, children with CF do not absorb fat normally. This leads to a deficiency in fat soluble vitamins, which are vitamins A, D, E, and K. This is a standard medication given every day, but is not the top priority when this client develops a fever. Choice D is incorrect. Albuterol is a bronchodilator frequently given as a nebulizer treatment to clients with CF. Although this medication might be given top priority if the client was experiencing respiratory difficulty, the question states they have developed a fever. Due to this finding, the IV antibiotics are the top priority as CF clients are very susceptible to infections. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care; Pediatric - Respiratory Additional Info Source : Archer Review Last Updated - 12, Feb 2022

While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect? Select all that apply. A. Patent Ductus Arteriosus (PDA) B. Congestive Heart Failure (CHF) C. Aortic Stenosis D. Ventricular Septal Defect (VSD) Submit Answer

Explanation Choices A and B are correct. The objective here is to identify that a patent ductus arteriosus can lead to congestive heart failure and must be suspected in an infant presenting with the symptoms mentioned in the question. The nurse does suspect a patent ductus arteriosus (PDA) (Choice A), due to the presence of a machine-like murmur, a hallmark sign of a PDA. The nurse also suspects congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding, irritability, and vomiting. Symptoms of congestive heart failure in infants with congenital heart disease are often misdiagnosed and treated as septicemia so, one should be aware of this presentation. PDA is an acyanotic type of congenital heart disease. Ductus arteriosus is the communication between the pulmonary artery and the aorta. Soon after a term birth, functional closure of the ductus arteriosus occurs from vasoconstriction. In some cases, it remains open (patent) and is referred to as PDA. A small PDA often does not cause any problem. If the PDA is large, it results in significantly increased pulmonary blood flow. A large left to right shunt through a PDA causes left atrial and left ventricular enlargement. The left ventricular end-diastolic pressure increases and eventually the left ventricle fails to handle the increased volume overload resulting in CHF. In 80% of infants with critical acyanotic congenital heart disease, congestive heart failure is the presenting symptom. Difficulty in feeding is common. This is often associated with tachypnea, sweating, and subcostal retraction. One should suspect congenital heart disease in such an infant if the feeding takes more than 30 minutes. A history of feeding difficulty often precedes overt congestive heart failure, even if only by six to 12 hours. Signs of congestive heart failure on physical exam include an S3 gallop and pulmonary rales. Congenital heart defects (CHD) are classified into two main categories: acyanotic and cyanotic. In acyanotic defects, congestive heart failure is the most common symptom. Whereas in cyanotic heart defects, the main concern is hypoxia. Choice C is incorrect. Aortic stenosis is the narrowing of the aortic valve. Critical aortic stenosis can cause congestive heart failure in an infant, but this would result in a systolic murmur, not a machine-like murmur, so the nurse does not suspect this. Choice D is incorrect. A ventricular septal defect (VSD) is an abnormal opening between the left and right ventricles. A large VSD can cause congestive heart failure in an infant but this would result in a pan-systolic murmur, not a machine-like murmur, so the nurse does not suspect this. You may watch the video below to understand the mechanism of important fetal circulation bypass defects including a PDA: NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological Adaptation Last Updated - 29, Dec 2021

Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? Select all that apply. A. Diaphoresis B. Weight loss C. Insomnia D. Poor feeding Submit Answer

Explanation Choices A and D are correct. Diaphoresis, or increased sweating (Choice A), is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire and this is manifested in signs such as diaphoresis. Diaphoresis is possibly related to a catecholamine surge and can mainly occur during feeding when the infant/child attempts to eat while in respiratory distress. Poor nutrition (Choice D) is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, there is fluid backing up in the lungs (pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients. Choice B is incorrect. Weight gain, rather than loss, is an expected clinical manifestation of heart failure. Weight gain is secondary to fluid retention. In heart failure (especially with right heart failure), the heart struggles to move fluid forward in the body and therefore liquid begins to back up, causing venous congestion and weight gain. Venous congestion in right-sided heart failure manifest with liver enlargement (hepatomegaly), ascites, pleural effusion, peripheral edema, and jugular venous distension. Venous congestion in left-sided heart failure manifests with tachypnea, intercostal retractions, nasal flaring or grunting, rales, and pulmonary edema. Primary mechanisms of fluid retention in heart failure include reduced renal perfusion and, thereby, activation of the renin-angiotensin-aldosterone system. Increased aldosterone production leads to sodium and water retention. Congestion in patients with chronic heart failure usually develops over weeks or even months. In the case of exacerbations of congestive heart failure (CHF), patients may present 'acutely' having gained several liters of excess fluid and hence several pounds of excess weight. Therefore, management in these acute CHF exacerbation patients involves removing that excess fluid (acutely retained fluid) and transitioning them back to a diagnosis of chronic heart failure. In managing clients with acute CHF exacerbation, daily weight monitoring is a crucial measure to monitor outcomes and achieve desired weight loss (removal of excess fluid). Loop diuretics are the principal agents to attain that target. Choice C is incorrect. Insomnia is not an expected clinical manifestation of heart failure in children. These patients are often very fatigued but do not typically experience insomnia. Although paroxysmal nocturnal dyspnea and orthopnea in left heart failure may cause some sleep disturbances, insomnia is not a commonly reported direct symptom of heart failure. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation. Last Updated - 06, Jul 2021

What is the best time to assess the respiratory rate of a young child? A. While the child is quietly sitting on the parent's lap B. While the child is crying C. While the child is playing in the playroom D. Immediately after assessing the child's blood pressure Submit Answer

Explanation Choice A is correct. Respirations are best determined while the child is sleeping or quietly awake. Choices B, C, and D are incorrect. When a child is playing or upset, respirations may increase because of the crying or activity. This could result in the appearance of a falsely abnormal finding. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Child, Comprehensive Physical Assessment Last Updated - 22, Jan 2022

When caring for an infant during cardiac arrest. Which pulse must be palpated to determine cardiac function? A. Carotid B. Brachial C. Pedal D. Radial Submit Answer

Explanation Choice B is correct. The brachial pulse is the most accessible pulse on an infant and, therefore, it is the site of choice. Accurate assessment of heart rate, breathing, and color is an essential part of infant resuscitation, and the guidelines state that heart rate may be assessed using a stethoscope, or palpating the umbilical, brachial, or femoral pulses. Choice A is incorrect. The carotid pulse may be difficult to palpate due to the fatty tissue that typically, and often, surrounds an infant's neck. Choice C and D are incorrect. The radial and pedal pulses may not be reliable indicators of cardiac function. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation Last Updated - 14, Nov 2021

Which of the following observations are non-reassuring when assessing a fetal heart rate strip? Select all that apply. A. Fetal bradycardia B. Variable decelerations C. Late decelerations D. Early decelerations Submit Answer

Explanation Choices A, B, and C are correct. A is correct. Fetal bradycardia, or a decrease in fetal heart rate below 110 bpm, is a non-reassuring sign on a fetal heart rate strip. When the nurse notes this sign, she will need to intervene by repositioning the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Also, fetal bradycardia is often a result of uterine hyperstimulation. If the client is on the oxytocin drip, the nurse should discontinue the infusion. B is correct. Variable decelerations, or sharp and profound drops in the fetal heart rate unrelated to the time of contractions, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Variable decelerations are often caused by cord compression, such as a prolapsed cord, and would be an emergency requiring quick nursing intervention. C is correct. Late decelerations, or dips in the fetal heart rate that occur after a contraction, are a non-reassuring sign on a fetal heart rate strip. Anytime that the nurse notes this sign, she will need to intervene by laying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Late decelerations are due to uteroplacental insufficiency and require intervention by the nurse. Choice D is incorrect. Early decelerations are not a non-reassuring sign on a fetal heart rate monitoring strip. Early decelerations are when the fetal heart rate decreases at the same time as a contraction. Early decelerations are due to the pressure of the head of the fetus on the pelvis or soft tissue and are characterized by a return to baseline at the end of the contraction. The nurse requires no intervention after an early deceleration. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Reduction of Risk potential; Problems with Labor and Delivery Last Updated - 11, Feb 2022

Which of the following signs and symptoms indicate right-sided heart failure in a pediatric patient? Select all that apply. A. Grunting B. Nasal flaring C. Ascites D. Hepatosplenomegaly Submit Answer

Explanation Choices C and D are correct. Ascites is indicative of right-sided heart failure. This would be due to the right ventricle not pumping sufficient amounts of blood to the lungs; therefore, the blood backs up in the body causing an increased amount of fluid in the interstitial space. Any signs or symptoms involving an increase in fluid status are indicative of right-sided heart failure (Choice C). Hepatosplenomegaly is indicative of right-sided heart failure. This would be due to the right ventricle not pumping sufficient amounts of blood to the lungs, and therefore blood backs up in the body causing an increased amount of fluid in the liver and spleen, which leads to their enlargement. Any signs or symptoms involving an increase in fluid status would be indicative of right-sided heart failure (Choice D). Choice A is incorrect. Grunting is a sign of left-sided heart failure in an infant. It is a classic sign of respiratory distress in an infant. This is a serious finding and should be reported to the health care provider immediately. Respiratory signs and symptoms indicate left-sided heart failure because the blood is backing up in the lungs due to the inability of the left ventricle to pump sufficient amounts out to the body. Choice B is incorrect. Nasal flaring is a sign of left-sided heart failure in an infant. It is a classic sign of respiratory distress in an infant. Respiratory signs and symptoms indicate left-sided heart failure because the blood is backing up in the lungs due to the inability of the left ventricle to pump sufficient amounts out to the body. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Cardiovascular Last Updated - 18, Dec 2021

The nurse is preparing to admit a newborn diagnosed with tetralogy of Fallot to the neonatal intensive care unit. The nurse knows that to maintain a patent ductus arteriosus the provider will order __________. Fill in the blank. A. Alprostadil B. Indomethacin C. Propranolol D. Morphine Submit Answer

Explanation Choice A is correct. Alprostadil will be administered to keep the ductus arteriosus open, or patent. This will allow more pulmonary blood flow to the child with low oxygen saturations while waiting for surgery. Choice B is incorrect. Indomethacin is used to close the patent ductus arteriosus (PDA), not to keep it open. Choice C is incorrect. Propranolol is a beta-blocker sometimes used in the management of a tetralogy of Fallot spell. It will not help keep the PDA open. Choice D is incorrect. Morphine is used to decrease pulmonary vascular resistance and calm the child during a tetralogy of Fallot spell but does not keep the PDA open. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological therapies, Pediatrics - Cardiac Last Updated - 09, Feb 2022

A night shift nurse is caring for a pediatric client admitted earlier in the day following a severe asthma attack. To promote comfort at the time the client is going to bed for the night, the nurse instructs the client to assume which position? A. High or semi-Fowler's position B. Prone position C. Side-lying position D. Supine position Submit Answer

Explanation Choice A is correct. Although this pediatric client initially presented with a severe asthma attack which has since resolved, this night shift nurse is correct in providing instruction regarding nocturnal sleep positioning, as nocturnal asthma exacerbation is a concern for this pediatric client. Nocturnal asthma symptoms are common and more pronounced in clients with more severe forms of asthma. This client, having required hospitalization due to a severe asthma attack, should be considered to have a more severe form of asthma. Here, the nurse should instruct the client to sleep in a high or semi-Fowler's position, as these two positions have been shown to be the most effective in preventing nocturnal asthma exacerbations. Choice B is incorrect. Sleeping in a prone position has been shown to increase the likelihood of a nocturnal asthma exacerbation. Choice C is incorrect. Sleeping in a side-lying position has been shown to increase pulmonary constriction and, subsequently, the likelihood of nocturnal asthma exacerbations. Choice D is incorrect. Sleeping in a supine position has been shown to increase the likelihood of nocturnal asthma exacerbations, primarily due to the worsening of several known contributing factors (i.e., gastroesophageal reflux disease and/or obstructive sleep apnea) and should therefore be avoided. Learning Objective When caring for a pediatric client following an asthma attack, recognize the need to instruct the client to sleep in a high or semi-Fowler's position to reduce the risk of a nocturnal asthma exacerbation. Additional Info In those with asthma, clients with more severe disease are significantly more likely to experience nocturnal asthma. The chances of experiencing asthma symptoms or an exacerbation are higher during sleep. Posture is an important determinant of pulmonary mechanics, which has critical implications for clients with asthma. Although the exact causation of nocturnal asthma has yet to be identified, certain contributing factors have been identified. Many of these contributing factors are exacerbated by the choice of one's sleeping position, including, but not limited to: Gastroesophageal reflux disease (GERD) Obstructive sleep apnea (OSA) Sinusitis (more specifically, postnasal drip)

The nurse is caring for a child diagnosed with a coarctation of the aorta who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lung sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following? A. Pulmonary congestion B. Foreign body aspiration C. Pneumonia D. Systemic congestion Submit Answer

Explanation Choice A is correct. Crackles and rales are indicative of pulmonary congestion. Because this child has coarctation of the aorta, there is too much blood backing up in the lungs. It is impossible for the left side of the heart to move sufficient blood forward working against the coarctation. This causes the back up of blood in the lungs, and therefore the crackles and rales are indicative of pulmonary congestion. Choice B is incorrect. Crackles and rales are not indicative of foreign body aspiration. The child presenting with a foreign body aspiration would be coughing, choking, have difficulty breathing and speaking, and might start to turn cyanotic. When the nurse auscultates that patient's lungs, she would hear wheezing and stridor instead of crackles and rales. Choice C is incorrect. While rales can sometimes be auscultated in pneumonia, crackles are not usually present. Instead the nurse would auscultate rhonchi. Additionally, because of the congenital heart defect coarctation of the aorta, the nurse knows that blood will be backing up in the lungs leading to pulmonary congestion. She does not suspect pneumonia in this patient. Choice D is incorrect. Crackles and rales are not indicative of systemic congestion, rather they are a sign of pulmonary congestion. Signs of systemic congestion would include splenomegaly, JVD, weight gain, edema, and ascites. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic care, comfort, Pediatrics - Cardiac Last Updated - 20, Dec 2021

The nurse is concerned that a child has epiglottitis. Which physical assessment finding is consistent with epiglottitis? A. Absence of spontaneous cough B. Harsh, productive cough C. Generalized skin flushing D. Coarse tremors Submit Answer

Explanation Choice A is correct. Epiglottitis has an abrupt onset and requires immediate treatment because it can cause progressive obstruction and may lead to respiratory arrest. The absence of spontaneous cough is a common feature of epiglottitis because of severe edema. Edematous epiglottis blocks the airway making it difficult to cough. Choices B, C, and D are incorrect. Epiglottitis causes an absence of a cough because of severe edema. Generalized skin flushing is not a feature of this condition, whereas cyanosis may be found because of hypoxia. Tremors are not a finding associated with epiglottitis. Learning Objective Understand that acute epiglottitis is a medical emergency. Recognize that a spontaneous cough may be absent in acute epiglottitis. Additional Info Epiglottis is a cartilaginous flap present at the back of the throat. It's primary function is to close over the airway during swallowing so that the food does not enter the airway. Acute epiglottitis is a medical emergency that has an abrupt onset. In epiglottitis, the epiglottis becomes inflamed and swollen and constructs the airway. Classic symptoms of epiglottis include - Sore throat and pain in swallowing Fever The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva Red and inflamed mucous membranes Large, cherry red, edematous epiglottis Prevention : Key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at two months of age. Source : Archer Review Last Updated - 03, Jul 2022

The nurse is taking care of a pediatric client after an asthma attack. To promote comfort, the nurse instructs the client to assume which position? Correct A. High Fowler's position [92%] B. Prone position [2%] C. Side-lying position [5%] D. Dorsal position

Explanation Choice A is correct. The High Fowler's position facilitates the breathing process for children after an asthma attack. Choices B, C, and D are incorrect. The prone, side-lying, and dorsal positions do not promote comfort in children after an asthma attack. Additional Info Source : Archer Review Last Updated - 19, Dec 2022

The nurse is teaching the parents of a client with cystic fibrosis. Which statement, if made by the parents, would require follow-up? A. "Chest physiotherapy should be done before giving bronchodilators." B. "The bronchodilator should be administered before strenuous activity." C. "My child may have trouble sleeping if the bronchodilator is given at night." D. "During a respiratory illness, my child should drink more water." Submit Answer

Explanation Choice A is correct. This statement is incorrect and requires follow-up. Bronchodilators should be administered before chest physiotherapy to enhance the mobilization of secretions, allowing them to be expelled. Choices B, C, and D are incorrect. These statements are correct and do not require follow-up. Bronchodilators should be administered before strenuous exercise to prevent respiratory distress. Specifically, short-acting bronchodilators such as albuterol need to be administered. Bronchodilators cause a discharge of catecholamines which may cause the client to have insomnia. Increasing the amount of non-caffeinated fluids is recommended during respiratory illnesses to assist with the thinning of secretions. Additional Info Last Updated - 24, Aug 2022

You are caring for an 8-month-old infant with a tracheostomy. Upon assessment, you visualize secretions within the tracheostomy that require suctioning. In preparation to suction the infant's tracheostomy, which of the following settings would be the most appropriate suction setting? A. 120 mmHg B. 90 mmHg C. 60 mmHg D. 40 mmHg Submit Answer

Explanation Choice B is correct. 90 mmHg would be the most appropriate suction setting for an 8-month-old infant based on the choices provided. For infants and children up to 24 months, tracheostomies should be suctioned using 80-100 mmHg. Choice A is incorrect. A suction setting of 120 mmHg is the upper limit for children aged 24 months and older. Therefore, this suction setting would be too powerful to utilize on an 8-month-old infant. Choice C is incorrect. 60-80 mmHg is the recommendation for suctioning newborns and neonates (i.e., up to 28 days). Therefore, 60 mmHg will likely not provide adequate suctioning power for this client. Choice D is incorrect. Attempting to suction a tracheostomy using 40 mmHg would not produce enough suctioning power to render a viable result. This pressure is not indicated for any age range. Learning Objective Identify the appropriate suction setting to use when suctioning an infant's tracheostomy. Additional Info Pressure setting for newborns and neonates: 60-80 mmHg Pressure setting for infants and children up to 24 months: 80-100 mmHg Pressure setting for children over 24 months and teens: 100-120 mmHg Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway that the client cannot clear by coughing. Suctioning should be performed in the morning, before bed, and when needed. Last Updated - 09, Sep 2022

The nurse is caring for a child admitted with congestive heart failure. Which of the following assessment findings would be expected? A. S1, S2 heart sounds B. Exercise intolerance C. Bradypnea D. Flattened neck veins Submit Answer

Explanation Choice B is correct. Exercise intolerance is common for a child with heart failure because the cardiac output cannot keep up with the demands of exercise. Fatigue may develop as well as irritability from the child's inability to participate in exercise-related activities. Choices A, C, and D are incorrect. Heart failure produces abnormal heart tones such as S3 and S4, referred to as gallop rhythm. An S3 heart tone is heard in systolic heart failure, whereas an S4 heart tone is expected in diastolic heart failure. S1 and S2 heart tones are normal and would be accompanied by S3 or an S4 heart sound if the client has either systolic or diastolic heart failure. Tachypnea is a common feature of heart failure because of decreasing lung compliance; this is often seen with tachycardia. Flattened neck veins are unexpected in heart failure, whereas distended neck veins are common because of increased venous pressure. Additional Info Congestive heart failure manifestations in children are similar to those in adults. These clinical features include - ➢ Abnormal heart tones (S3/S4) ➢ Exercise intolerance ➢ Fatigue ➢ Orthopnea ➢ Weight gain ➢ Adventitious lung sounds ➢ Neck vein distention (this cannot be observed in infants because of their short necks) Last Updated - 12, Dec 2022

A 15-year-old admitted for status asthmaticus has been stabilized. Which activity would be most appropriate for the client? A. Completing a jigsaw puzzle B. Talking on the phone with friends C. Watching basketball on television D. Putting together a necklace Submit Answer

Explanation Choice B is correct. Peer groups play a significant role in the socialization of adolescents. Teenagers need an opportunity to interact with their peers during sickness to allow them an outlet to express their concerns. Allowing teenage clients to speak with friends over the phone enables the teenage client to accomplish these needs. Additionally, it is important to note that this activity is being encouraged following the stabilization of the client. Choice A is incorrect. Since peer groups play such a significant role in the socialization of adolescents, teenagers should be provided an opportunity to interact with peers during their times of sickness to facilitate an outlet to express their concerns. Assembling a jigsaw puzzle would not provide the teenager with an opportunity to accomplish this. Choice C is incorrect. Watching television would not provide this teenage client with an opportunity to interact with members of their peer group. Choice D is incorrect. Even during times of sickness, teenagers need an outlet to express their concerns and interact with their peer group. Assembling a necklace (or other arts and crafts) would not provide this teenage client an opportunity to socialize with their peer group. Learning Objective Recognize the importance of a teenage client's peer group in the client's social structure. Additional Info Peers serve as credible sources of information, serve as role models of social behaviors, and provide sources of social reinforcement. Socialization with peers should be strongly encouraged. Last Updated - 02, Sep 2022

The nurse is assessing a 2-year-old client with the following symptoms: excessive drooling, stridor, difficulty swallowing, and difficulty speaking. Based on these assessment findings, which condition does the nurse suspect? A. Croup B. Epiglottitis C. Laryngotracheal bronchitis D. Bronchiolitis Submit Answer

Explanation Choice B is correct. The cardinal signs of epiglottitis are the "4 Ds" - drooling, dysphonia, dysphagia, and distress. Difficulty swallowing is dysphagia and difficulty speaking is dysphonia. Stridor is a high-pitched wheezing sound caused by disrupted airflow, hence the distress. This child is presenting with all of those cardinal symptoms and is therefore highly suspicious of epiglottitis. Choice A is incorrect. Croup is a respiratory infection presenting with a loud barking cough. It does not cause airway obstruction. Choice C is incorrect. Laryngotracheal bronchitis is another name for croup. The cardinal sign of this disorder is a loud, barking cough. It is sometimes described as a "seal-like" barking cough. It lasts 3-5 days and the child is typically febrile. Choice D is incorrect. Bronchiolitis is inflammation of the bronchioles or lower airway. It is characterized by a runny nose, fever, and cough. Children with bronchiolitis do not present with the signs of airway obstruction described; those are very specific to epiglottitis. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatric - Respiratory Additional Info Source : Archer Review Last Updated - 05, Feb 2022

An infant is currently stable but has just been diagnosed with cystic fibrosis. Which of the following would be the priority nursing goal for the family? A. Stabilize the child B. Provide emotional support C. Arrange for financial assistance D. Formulate long-term goals Submit Answer

Explanation Choice B is correct. The family needs emotional support when a chronic condition is newly diagnosed in a family. The parents need to follow up on genetic counseling, treatment options, prognosis, and resources. Choice A is incorrect. The infant has already been stabilized, so there is no longer a need to adjust care for the infant. Choice C is incorrect. This is a long-term goal for the family. Choice D is incorrect. This is a long-term goal for the family. Last Updated - 09, Sep 2022

You are the nurse in a pediatrician's office. An 8-year-old boy with a history of asthma is brought to the office with complaints of a drippy nose, congestion, and runny eyes. The NP sees the patient and makes the diagnosis of allergic rhinitis. The NP prescribes an intranasal corticosteroid and an intranasal antihistamine. The outcome from allergic rhinitis that would put this child at highest risk is: A. Impaired sleep B. Decreased school performance C. An asthma attack D. Irritability Submit Answer

Explanation Choice C is correct. An asthma attack would put this child at the highest risk. Studies show that uncontrolled allergic rhinitis can make asthma much more challenging to manage. Since this child has a history of asthma, he should be treated aggressively to manage allergic rhinitis. Choices A, B, and D are incorrect. Although impaired sleep, decreased school performance, and irritability are all risks associated with allergic rhinitis, asthma is a life-threatening illness that must be treated quickly. Anything that interferes with that treatment (such as allergic rhinitis) should be avoided. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Health Promotion/Disease Prevention, Respiratory Additional Info Source : Archer Review Last Updated - 19, Dec 2022

The nurse is reinforcing education to the parents of a toddler diagnosed with bronchiolitis. The nurse informs the parents that which of the following is the most likely cause of bronchiolitis? A. Haemophilus influenzae type B B. Adenovirus C. Respiratory Syncytial Virus D. Rhinovirus Submit Answer

Explanation Choice C is correct. Respiratory Syncytial Virus (RSV) is the most likely cause of bronchiolitis. It is a common virus in children that causes respiratory illness and is especially common in children less than 2-years-old. Choice A is incorrect. Haemophilus influenzae type B (HiB) is not the most likely cause of bronchiolitis. This infection is the common cause of epiglottitis, an inflammation of the epiglottis causing an airway emergency. The HiB vaccine has greatly reduced the incidence of this disease. Choice B is incorrect. Adenovirus is not the most likely cause of bronchiolitis. Adenoviruses are common viruses that cause a range of illnesses. They can cause cold-like symptoms, fever, sore throat, pneumonia, diarrhea, and conjunctivitis. Choice D is incorrect. Rhinovirus is not the most likely cause of bronchiolitis. Rhinovirus is the most common viral infectious agent in humans and is the predominant cause of the common cold. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Infection control and safety, Pediatric - Respiratory Last Updated - 28, Jan 2022

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children? A. Hyoid B. Arytenoid C. Cricoid D. Thyroid Submit Answer

Explanation Choice C is correct. The cricoid appears as a full circular ring and is the most narrow part of the airway. While intubating, it can be useful to place pressure on the cricoid to make the airway more comfortable to access. Choice A is incorrect. The hyoid is a semi-circle ring, not a circular ring. It helps support the tongue. Choice B is incorrect. The arytenoid muscle is at the back of the larynx and allows the vocal cords to work correctly. Choice D is incorrect. The thyroid is an organ that sits below the "Adam's apple" and is not a part of the airway. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Pathophysiology, Respiratory System Last Updated - 12, Jul 2021

A 14-year-old is admitted to the medical ward for status asthmaticus. He was put on IV theophylline. Which manifestation would the nurse consider as a side effect of the drug? A. Grand mal seizures B. Severe palpitations C. Hypotension D. Headache Submit Answer

Explanation Choice D is correct. Headache is one of the most common side effects of theophylline. It is essential to understand the difference between a side effect and drug toxicity- a side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity (adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range. Common side effects of theophylline include headache, restlessness, nausea, and sleeplessness. On the other hand, the clinical manifestations of theophylline drug toxicity/ theophylline poisoning include cardiac dysrhythmias (presenting as palpitations, cardiac arrest), hypotensive shock, seizures/ status epilepticus, and refractory vomiting. Choice A is incorrect. Seizures are a sign of toxicity from theophylline, not just a common side effect. Choice B is incorrect. Palpitations and arrhythmias are a sign of theophylline drug toxicity as well. Choice C is incorrect. Hypotension and shock are seen with theophylline overdose/ drug toxicity and is not common side effect. Learning Objective Recognize the differences between a side effect and drug toxicity. Understand the common side effects of theophylline versus its toxic effects. Additional Info Source : Archer Review Last Updated - 21, Sep 2022

The nurse is caring for a 4-year-old client in respiratory distress. The nurse knows to assess for which complication that frequently occurs with respiratory distress? A. Ectopy B. Irritability C. Sepsis D. Dehydration Submit Answer

Explanation Choice D is correct. Dehydration is a frequent complication of respiratory distress and the nurse must know to monitor for this. Tachypnea (rapid breathing) is often seen in children with respiratory distress. Additionally, mouth breathing is common in children due to nasal congestion, edema, and inflammation. As these children expire more and more frequently, significant insensible fluid losses occur. Since children with respiratory distress do not take enough fluids by mouth, their intake is rarely enough to keep up with their insensible losses. Therefore, dehydration frequently occurs in a child experiencing respiratory distress. If the child is receiving humidified oxygen, insensible losses from tachypnea are minimal. Otherwise, it's important that the maintenance fluids include an additional 20-50% to the respiratory replacement in a child with tachypnea. Choice A is incorrect. Ectopy refers to certain changes in an otherwise normal heart rhythm. Ectopy may involve extra heartbeats or skipped heartbeats. The most common forms of ectopy are premature atrial contractions (PACs) or premature ventricular contractions (PVCs). Some causes of PVCs include myocardial ischemia, hypoxia, excess caffeine use, and drug abuse. While PVCs may occur with hypoxia in respiratory distress, this is not a frequent complication Choice B is incorrect. Irritability in a 4-year-old client is an important symptom to monitor for, but it is not a complication that frequently occurs with respiratory distress. When a child is in respiratory distress and struggling to breathe, they most often become tired. Therefore lethargy, not irritability, would be the complication to monitor. Choice C is incorrect. Sepsis is a life-threatening condition due to the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death. While a child may experience respiratory distress due to sepsis, sepsis itself is not a complication of respiratory distress. Learning objective: Children with tachypnea lose excess water from the lungs unless they are receiving humidified oxygen. Maintenance fluids should account for this insensible loss otherwise, dehydration ensues. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Risk potential reduction Last Updated - 25, Aug 2021

The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching? A. "Before use, I should put the sliding marker at the top of the numbered scale." B. "I should have my child sit at a 45-degree angle while performing this procedure." C. "My child should inhale as quickly as they can through the mouthpiece." D. "I should record the highest of the three readings." Submit Answer

Explanation Choice D is correct. The child's highest reading out of three times should be recorded (not the average). It is important that between each measurement, a 30-second rest is taken by the child. Choices A, B, and C are incorrect. The peak flow meter is a great tool for the client to determine the control of their asthma. Prior to the child measuring their peak flow, the device should be reset by sliding the marker (or arrow) on the meter by placing it at the bottom of the numbered scale. The child should not be sitting for this measurement; rather, they should be standing upright to allow for maximum chest expansion. The peak flow meter measures expiratory volume, so the child should be instructed to blow as hard and quickly as possible. Additional Info Use of a Peak Expiratory Flow Meter 1. Before each use, make certain the sliding marker or arrow on the peak expiratory flow meter is at the bottom of the numbered scale. 2. Stand up straight. 3. Remove gum or food from your mouth. 4. Close your lips tightly around the mouthpiece. Be certain to keep your tongue away from the mouthpiece. 5. Blow out as hard and as quickly as you can, a "fast, hard puff." 6. Note the number by the marker on the numbered scale. 7. Repeat entire routine three times, but wait at least 30 seconds between each routine. 8. Record the highest of the three readings, not the average. 9. Measure your peak expiratory flow rate (PEFR) close to the same time and same way each day (e.g., morning and evening; before and 15 minutes after taking medication). 10. Keep a record of your PEFRs. Wilson, D., Hockenberry, M. (102018). Wong's Nursing Care of Infants and Children, 11th Edition. Last Updated - 13, Jan 2023

While working in the emergency department, the nurse assesses a 3-day old infant brought in by the mother. The mother states, "My baby is always so sweaty and hot, and just doesn't want to eat! I think something is wrong." The nurse is unable to palpate a femoral pulse but notes +3 brachial pulses. Based on this assessment, which congenital heart defect does the nurse suspect? A. Hypoplastic left heart syndrome (HLHS) B. Patent ductus arteriosus (PDA) C. Transposition of the great arteries (d-TGA) D. Coarctation of the aorta (COA) Submit Answer

Explanation Choice D is correct. The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any of it can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses. Choice A is incorrect. The nurse does not suspect that this infant has hypoplastic left heart syndrome (HLHS). HLHS is characterized by a very small, underdeveloped left atrium, ventricle, and aorta. Essentially, the entire left side of their heart is not developed. This infant will appear cyanotic and quickly show signs of heart failure, but will not present with absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. Choice B is incorrect. The nurse does not suspect that this infant has a patent ductus arteriosus. The ductus arteriosus is a normal duct in fetal circulation which allows oxygenated blood to shunt from the pulmonary artery to the aorta and bypass pulmonary circulation. It should close shortly after birth, but if it does not, it is known as a patent ductus arteriosus (PDA). These infants present with a machine-like murmur but do not have absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. Choice C is incorrect. The nurse does not suspect that this infant has transposition of the great arteries. In this defect, the pulmonary artery and aorta are switched. This creates two separate loops for blood circulation: deoxygenated blood entering the right atrium from the body and then being sent directly back out to the body via the transposed aorta, and oxygenated blood entering the left atrium from the lungs and being sent back to the lungs via the transposed pulmonary artery. These two closed loops can only be connected via a hole in the septum; either an ASD, VSD, PDA, or PFO. The child will be dependent on one of these holes for any systemic oxygenation. They will be very cyanotic at birth but do not have absent femoral pulses and +3 brachial pulses. The nurse suspects a different congenital heart defect. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological adaptation, Pediatrics - Cardiac Last Updated - 16, Dec 2021

The nurse is caring for a teenager who is recovering from a tonsillectomy. The nurse walks into the room and sees the client eating chips and salsa from a Mexican restaurant. Which response by the nurse is most appropriate? A. "I love that restaurant! Their chips are so good." B. "You cannot eat anything yet, I am sorry." C. "Chips are not a good choice right now because you need a high protein diet after your surgery." D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now." Submit Answer

Explanation Choice D is correct. This is the most appropriate response by the nurse. She correctly explains to the client that the sharp tortilla chips would be really hard on the surgical site after a tonsillectomy. Allowing clients to eat foods like chips or popcorn after surgery in the back of the throat would put them at risk for damage to the incision and subsequent hemorrhage. Offering the client something soft, such as jello or soup, is what is most appropriate. Choice A is incorrect. This is not an appropriate response. The client should not be eating anything hard or sharp like chips after a tonsillectomy. That food could damage the surgical area at the back of the throat and cause postoperative complications such as hemorrhage and sore throat. Choice B is incorrect. This is not an appropriate response. It is fine for the client to eat, but they will need to start with a soft diet in order to protect the surgical site. It is not necessary to keep the client NPO after their surgery has finished and the gag reflex has returned. Choice C is incorrect. This is not an appropriate response. Although the nurse correctly identified that chips are not a good choice after surgery, she gave the client incorrect information about the reason. Clients after a tonsillectomy need a soft diet, not a diet that is high in protein. NCSBN Client Need: Topic: Health promotion and maintenance; Subtopic: Pediatric - HEENT Last Updated - 15, Feb 2022

The nurse is reviewing tetralogy of Fallot with a nursing student. It would indicate effective teaching if the student identifies which defects with this disorder? Select all that apply. A. Ventricular septal defect (VSD) B. Overriding aorta C. Pulmonary artery stenosis D. Concentric right ventricular hypertrophy E. Mitral valve regurgitation Submit Answer

Explanation Choices A, B, C, and D are correct. Tetralogy of Fallot is a congenital heart defect composed of four errors, a ventricular septal defect (VSD) being one of them. The VSD is a hole between the right and left ventricles, allowing the oxygenated and deoxygenated blood to mix in, essentially one ventricle. An overriding aorta being one of them is another feature. This means the aorta is positioned over the VSD instead of over the left ventricle, where it should be. Pulmonary stenosis is another feature of ToF. The pulmonary arteries are narrowed and hardened, making it difficult for the right ventricle to pump blood to the lungs. Right ventricular hypertrophy is one of them. This portion of the error is actually due to another part: pulmonary stenosis. Since these vessels are narrowed and hardened, it is difficult for the right ventricle to pump blood through them and out to the lungs. This puts extra work on the heart, and after some time, the muscle of the right ventricle gets more substantial or hypertrophied due to the extra work. Choice E is incorrect. Mitral valve regurgitation is not a feature of ToF. In MVR, the client has incomplete valve closure during systole. Additional Info ✓ Calming the infant or child is an early intervention for hypercyanotic episodes. ✓ Additionally, the nurse should increase systemic vascular resistance by placing the infant's knees to their chest or having the child squat. ✓ Other key interventions include the administration of prescribed oxygen, morphine, and isotonic saline. Last Updated - 01, Feb 2023

The nurse is caring for a child experiencing multiple hypercyanotic episodes associated with tetralogy of Fallot. Which medication should the nurse anticipate from the primary healthcare provider (PHCP)? A. Morphine B. Furosemide C. Enalapril D. Formoterol Submit Answer

Explanation Choice A is correct. Morphine, for some unknown reason, is a medication utilized for refractory hypercyanotic episodes. It is theorized that this medication's sedative effect will calm the child and decrease the oxygen demand. Choices B, C, and D are incorrect. Furosemide would be contraindicated because this would decrease blood volume and could compromise perfusion. ACE-I's would be contraindicated because of their ability to decrease systemic vascular resistance (SVR). Increasing SVR is crucial to forcing blood into its appropriate chambers. Formoterol is a bronchodilator that could worsen the cyanotic spell because of the medication's ability to raise the heart rate. This increase in the heart rate would further demand more oxygen-rich blood flow. Additional Info Calming the infant or child is an early intervention for hypercyanotic episodes. Additionally, the nurse should increase systemic vascular resistance by placing the infant's knees to their chest or having the child squat. Other key interventions include the administration of prescribed oxygen, morphine, and isotonic saline. Last Updated - 14, Dec 2022

When assessing a four-month-old male infant, the nurse correctly evaluates his heart rate by performing which of the following actions? A. Auscultates the left 4th intercostal space for 60 seconds. B. Palpates the left 5th intercostal space for 30 seconds. C. Palpates the brachial pulse for 60 seconds. D. Auscultates the radial pulse for 30 seconds. Submit Answer

Explanation Choice A is correct. Auscultating the apical pulse for 60 seconds is the most accurate way to assess the heart rate of a 4-month-old infant. The nurse should auscultate instead of palpate because it is difficult to accurately count the pulse rate via palpation on a moving 4-month-old. Due to irregularities, a full minute should be auscultated to ensure the most accurate heart rate is recorded. The apex is the best location for this assessment, and in infants, it is located at the 4th intercostal space (ICS) to the left of the sternum at the midclavicular line. In adults, the apex is located at the 5th intercostal space (ICS) to the left of the sternum at the midclavicular edge. Choice B is incorrect. It is not most accurate to palpate the apical pulse; the nurse should auscultate instead. Also, the apex is located at the left 4th intercostal space in infants, not at the 5th intercostal space. Additionally, it is most accurate to auscultate for a full 60 seconds, not just 30 seconds. Choice C is incorrect. The brachial pulse is not the most accurate location for assessment of the heart rate in a 4-month-old infant. Auscultation of the apical pulse should be performed. Choice D is incorrect. The radial pulse is not the most accurate location for assessment of the heart rate in a 4-month-old infant. Auscultation of the apical pulse should be performed. NCSBN Client Need: Topic: Effective, safe care environment, Subtopic: Coordinated care Last Updated - 07, Feb 2022

The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % What is the priority action for the nurse to take at this time? A. Keep the child calm and call for emergency airway equipment B. Obtain IV access C. Assess the throat for a cherry red epiglottis D. Place the child on a high flow nasal cannula at 100% FiO2 Submit Answer

Explanation Choice A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious to have this medical emergency. In addition, this client is already showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway and the airway is always the priority. Choice B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment. Choice C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although the presence of a cherry red epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect the airway before IV access is attempted. Choice D is incorrect. Placing the child on a high-flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer but this intervention addresses the "C" in the ABC's mnemonic - circulation but the priority is always the airway. This child is at risk of losing their airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child, then their airway could spasm and obstruct completely, making it impossible to intubate them. That is why keeping the child calm and calling for emergency airway equipment is the priority in epiglottitis patients. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Risk potential reduction, Pediatric - Respiratory Additional Info Source : Archer Review Last Updated - 17, Jan 2022

A 16-year old patient injures her ankle on the soccer field. She is taken to the emergency department by ambulance. In the ambulance, she starts hyperventilating. Upon arrival to the waiting room, an arterial blood gas is drawn. What values will most likely appear on the results? A. pH: 7.55, CO2: 22, HCO3: 24 B. pH: 7.35, CO2: 39, HCO3: 26 C. pH: 7.32, CO2: 47, HCO3: 25 D. pH: 7.55, CO2: 42, HCO3: 34 Submit Answer

Explanation Choice A is correct. Hyperventilating can cause respiratory alkalosis. This is because there the body is blowing off too much CO2. CO2 is an acid, so when the body is loosing too much of it, the client can become alkalotic. Choice B is incorrect. These values represent typical ABG values, which would not be expected in a patient who is hyperventilation. Choice C is incorrect. These values represent respiratory acidosis, which is not caused by hyperventilation. Respiratory acidosis is more likely to occur when the patient is hypoventilating, and retaining too much CO2. Common causes of this are an overdose or respiratory depression. Choice D is incorrect. These values represent metabolic alkalosis, which would not be expected in the patient who is hyperventilating. Because it is a change in CO2 causing the pH to shift, the cause of the imbalance is respiratory, not metabolic. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Fluid and Electrolyte Imbalances, Fluid, Electrolyte, and Acid-Base Imbalances Last Updated - 27, Jan 2022

You are caring for a 1-month-old patient who has a sudden cardiac arrest. Which pulse should you palpate to determine circulatory status? A. Brachial B. Femoral C. Carotid D. Popliteal Submit Answer

Explanation Choice A is correct. In infants, the brachial artery is the right site to check for a pulse. This will help determine how to proceed with the code event and if there is a return of spontaneous circulation (ROSC). Choice B is incorrect. While the femoral artery is an appropriate place to check a pulse in an infant, this is not the location the AHA advises checking for a pulse during a cardiac arrest. Choice C is incorrect. The carotid artery is the correct location to palpate a pulse during a cardiac arrest in the adult client, not the infant client. Choice D is incorrect. The popliteal artery is a problematic pulse to palpate and should not be your point of reference for a pulse in any patient during a cardiac arrest. NCSBN Client Need: Topic: Physiologic Integrity, Subtopic: Reduction of Risk Potential, Emergency Care Last Updated - 11, Dec 2021

While working in a pediatric cardiac unit, you are assigned to take care of an infant with tetralogy of Fallot. During report, you are told that the infant is having frequent 'tet spells'. To prepare for your shift, which medication do you ensure is readily available in case of a tet spell? A. Morphine sulfate B. Dexmedetomidine C. Fentanyl D. Atropine sulfate Submit Answer

Explanation Choice A is correct. Morphine sulfate is the drug of choice for use during tet spells. It helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and therefore the hypercyanotic tet spell. Choice B is incorrect. Dexmedetomidine is a sedative. It is not used for tet spells. Choice C is incorrect. Fentanyl is a narcotic used for pain relief. Although it is similar in some ways to morphine sulfate, it is not used for tet spells. Choice D is incorrect. Atropine sulfate is an anticholinergic. It is used for several different purposes such as treating a slow heart rate or to decrease saliva production prior to surgery, but it is not used for tet spells. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Cardiovascular Last Updated - 23, Jan 2022

The nurse preceptor supervises a new nurse caring for a child with epiglottitis. Which action by the new nurse would require the nurse preceptor to intervene? The new nurse A. obtains a throat culture. B. positions the client high-Fowlers. C. initiates peripheral vascular access. D. places a bag-valve mask at the bedside. Submit Answer

Explanation Choice A is correct. Obtaining a throat culture would require immediate follow-up because this may cause acute laryngospasm leading to respiratory obstruction. The culture may be obtained once an artificial airway has been established. Choices B, C, and D are incorrect. These actions are appropriate during acute epiglottitis. High Fowler's position would assist with respiration. Peripheral vascular access is necessary to administer broad-spectrum antibiotics and corticosteroids. Airway equipment such as a bag-valve mask should be kept at the bedside in the event the client requires intubation. This may be used to oxygenate the client before intubation temporarily. Additional Info Epiglottis is a cartilaginous flap present at the back of the throat. It's primary function is to close over the airway during swallowing so that the food does not enter the airway. Acute epiglottitis is a medical emergency that has an abrupt onset. In epiglottitis, the epiglottis becomes inflamed and swollen and constructs the airway. Classic symptoms of epiglottis include - Sore throat and pain in swallowing Fever The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva Red and inflamed mucous membranes Large, cherry red, edematous epiglottis Prevention : Key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at two months of age. Source : Archer Review Last Updated - 10, Oct 2022

The nurse is caring for a client receiving digoxin. It would be a priority for the nurse to monitor the client's A. potassium. B. calcium. C. sodium. D. phosphorus. Submit Answer

Explanation Choice A is correct. The nurse must monitor potassium levels while the client is taking digoxin. Low levels of potassium may precipitate digoxin toxicity. Choices B, C, and D are incorrect. Calcium, sodium, and phosphorus do not have a relationship with digoxin. While the nurse should always monitor all electrolyte levels, potassium is what the nurse should watch most closely while the client takes digoxin because of its ability to precipitate toxicity. Additional Info Digoxin is a cardiac glycoside utilized in the treatment of atrial fibrillation and heart failure. While this medication has fallen out of favor because of its numerous interactions, this medication is still available. The apical pulse must be obtained prior to administering this medication. The apical pulse must be at least 60/minute for adults; 70/minute for children; and 90/minute for infants. The therapeutic level for digoxin is 0.5-2 ng/mL Last Updated - 18, May 2022

The nurse is assessing a child with reports of right eye irritation, drainage, and itchiness. This client is at highest risk for A. Conjunctivitis B. Amblyopia C. Nystagmus D. Ocular herpes Submit Answer

Explanation Choice A is correct. This client is demonstrating classic manifestations of conjunctivitis. Conjunctivitis is characterized by Itching, burning, or scratchy eyelids. Additionally, the client has drainage to the affected eye(s), a common conjunctivitis finding. Choices B, C, and D are incorrect. Amblyopia is, also known as 'lazy eye,' is not an infectious process and is characterized by differences between the two eyes in their ability to focus. Nystagmus is also a condition that is not infectious and is characterized by repetitive and uncontrolled movements of the eye. Ocular herpes is a viral infection that does not produce drainage. Additional Info The clinical signs of conjunctivitis are redness and swelling of the conjunctiva, eyelid edema, and discharge. Conjunctivitis may be viral (in most cases), bacterial, or allergic. Treatment is aimed at the underlying cause, which includes ophthalmic antibiotics for bacterial conjunctivitis. Symptomatic measures that can be taken to mitigate discomfort include intermittent wiping of the eye to remove debris (wipe inner canthus > outer). Additionally, for viral and bacterial causes, the nurse should stress the importance of meticulous hand hygiene to prevent the spread of the infection. The client should be instructed not to wear contact lenses during the infection. Last Updated - 05, Sep 2022

Which of the following images correctly demonstrates an atrial septal defect? A . B . C . D . Submit Answer

Explanation Choice A is correct. This image shows a heart with an atrial septal defect (ASD) or communication between the left and the right atrium. An ASD leads to the mixing of blood as it passes along the opening in the interatrial septum. Since the pressure on the left side is higher than the right, oxygenated (pure) blood moves from left atrium to right atrium (left to right shunt), then to the right ventricle, across the pulmonic valve, and then into pulmonary circulation (lungs). This type of left to right shunting does not cause cyanosis. If the ASD is small, the shunting is insignificant. On the other hand, if the ASD is large, a large volume left-to-right shunt increases the preload on the right ventricle. As a result, the right ventricle hypertrophies and eventually fails (heart failure). In addition, continued increased blood flow through the pulmonary valves into pulmonary arteries and lungs ends up causing pulmonary hypertension. Therefore, the complications of a large ASD include heart failure and pulmonary hypertension. Patients may present with dyspnea, fatigue, exercise intolerance, palpitations, or signs of right-sided heart failure. Arrhythmias may occur. A stroke or a transient ischemic attack following a diagnosis of deep venous thrombosis should raise a strong suspicion of ASD (venous blood clot moving through the ASD to the arterial side and causing a stroke). ASD Murmur: In a moderate to large ASD, the nurse can auscultate a crescendo-decrescendo systolic ejection murmur (second intercostal space at the left sternal border, pulmonic area). The murmur occurs because the left-to-right shunt results in increased right ventricular stroke volume across the pulmonary valve. The murmur is quiet at the beginning of systole, increases mid-systole, and then decreases at the end of systole (crescendo-decrescendo) Choice B is incorrect. This image shows a heart with coarctation of the aorta, a narrowing or stricture in the aorta. Choice C is incorrect. This image shows a heart with a ventricular septal defect; communication between the left and right ventricles. Choice D is incorrect. This image shows a heart with truncus arteriosus, a defect where the pulmonary artery and aorta formed into one vessel instead of two separate ones. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care, Cardiology Last Updated - 01, Feb 2022

The nurse is caring for a 3-year-old client diagnosed with bronchitis. The mother asks the nurse what this diagnosis means. Which response most correctly explains the diagnosis of bronchitis? A. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract." B. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." C. "Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the upper part of the respiratory tract." D. "Bronchitis occurs when an infection causes inflammation in the small airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract." Submit Answer

Explanation Choice A is correct. This statement correctly describes bronchitis to the mother. Bronchitis occurs when an infection causes inflammation in the large airways. These include the trachea and bronchi, which are in the lower part of the respiratory tract. Choice B is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the inflammation is in the small airways - these are the bronchioles and inflammation here would be termed bronchiolitis. Additionally, it states that the trachea and bronchi are in the upper part of the respiratory tract, which is also not true. They are in the lower part of the respiratory tract. Choice C is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the large airways are in the upper part of the respiratory tract and this is not true. The large airways, i.e. trachea and bronchi, are in the lower respiratory tract. Choice D is incorrect. This statement does not correctly describe bronchitis. It incorrectly states that the inflammation is in the small airways - these are the bronchioles and inflammation here would be termed bronchiolitis. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic care, comfort, Pediatric - Respiratory Last Updated - 21, Jan 2022

The nurse is planning care for a child who has had a near drowning at a local swimming pool. It would be a priority for the nurse to have which item at the bedside? A. Warm isotonic fluids B. Advanced airway C. Rectal thermometer D. Defibrillator Submit Answer

Explanation Choice B is correct. Drowning may cause a catastrophic pulmonary injury, and maintaining the client's airway to deliver warm, humidified oxygen is essential. While thermoregulation needs to be attained (drowning results in a decrease in body temperature), the essential item to have is airway equipment. Restoring a client's airway will prevent a serious complication of an anoxic brain injury. Choices A, C, and D are incorrect. Warm isotonic fluids are used in drowning to assist in stabilizing the client's temperature, and a rectal temperature is the most accurate way to obtain the core body temperature. However, these items, including the defibrillator, are not the priority compared to the client's airway patency. Additional Info Drowning poses a significant threat to young children and adults who cannot swim. The priority concern associated with drowning is the pulmonary insult caused by the loss of surfactant that impairs gas exchange. An essential treatment for drowning is early cardiopulmonary resuscitation (CPR). Additional therapies include warming measures to stabilize the client's temperature and prescribed antibiotics to prevent aspirational pneumonia. Last Updated - 27, Dec 2022

You receive the change-of-shift report for an infant whose family has just been informed of the infant's cystic fibrosis diagnosis. As the nurse caring for this pediatric client and the family, which of the following should you prioritize? A. Arrange and schedule a follow-up appointment with a pediatric pulmonologist B. Provide emotional support for the family C. Arrange for financial assistance D. Arrange for parental genetic testing, as the parents mention they want another child soon Submit Answer

Explanation Choice B is correct. Following the recent diagnosis of a chronic and incurable genetic condition such as cystic fibrosis, this family will require significant emotional support. Throughout the shift, the parents will likely have numerous questions regarding the need to follow up on genetic counseling, treatment options, prognosis, and/or resources, making Choice B the priority. Choice A is incorrect. Based on the information in this question, there is no indication that this infant's discharge is pending, nor has a pediatric pulmonology referral been written. Choice C is incorrect. Arranging for financial assistance is typically a lengthy, multi-step process. Procurement of financial assistance is the type of goal one would establish as a long-term goal for this family. Choice D is incorrect. The parents must understand the risks of conceiving additional children but at this time, arranging for parental genetic testing is not the priority. Learning Objective Recognize the need to prioritize providing emotional support to a family of an infant who recently received a chronic diagnosis of cystic fibrosis. Additional Info Source : Archer ReviewSource : Archer Review Last Updated - 09, Sep 2022

The nurse is monitoring a 10-year-old client post-op following a tonsillectomy. Which assessment finding should the nurse immediately report to the healthcare provider? A. Drooling B. Frequent swallowing C. Sneezing D. Moaning Submit Answer

Explanation Choice B is correct. Frequent swallowing is a sign of hemorrhage and should be immediately reported to a healthcare provider. If the patient has a hemorrhage at the surgical site in the back of their throat there will be blood running down the back of their throat causing them to constantly swallow. The nurse must monitor closely for this complication. Choice A is incorrect. Drooling in a patient who has just had a tonsillectomy is not uncommon and does not need to be immediately reported to a healthcare provider. Drooling would likely indicate inflammation around the surgical site at the back of the throat making it painful to swallow. The painful swallowing causes drooling. Since this is expected, it does not need to be immediately reported. Choice C is incorrect. Sneezing is not a sign of any postoperative complication. It does not need to be closely monitored for nor reported immediately to a healthcare provider. Choice D is incorrect. Moaning would likely indicate pain, which is expected in a child who had surgery. They should have orders for PRN pain medications that the nurse can administer. Moaning would not be a reason that the nurse must immediately notify the healthcare provider. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Risk potential reduction; Pediatric - HEENT Last Updated - 08, Feb 2022

An emergency department nurse is caring for a pediatric client who arrived experiencing an acute asthma attack. Once controlled, the nurse interviews the client's parents to determine which of the pediatric client's activities could precipitate the client's asthma attacks. Which statement by the parents would warrant the nurse to provide additional teaching? A. "Our child loves playing the trumpet in the grade school band." B. "Our child rakes leaves every Saturday afternoon to help with the work at home." C. "Our child participates in extracurricular activities." D. "Our child swims five laps twice a week with friends." Submit Answer

Explanation Choice B is correct. Raking leaves exposes the child to allergens from the trees. The nurse should advise the parents to seek an alternative activity that will allow the child to continue to help with the work at home but minimize exposure to potentially asthma attack-inducing allergens. Choice A is incorrect. Although studies vary across the board, there is no reliable, large-scale study showing the use of brass instruments (including trumpets) is harmful to those with asthma. Choice C is incorrect. Extracurricular activities are encouraged to promote maturity, develop social skills, and foster friendship among colleagues in children. Choice D is incorrect. Swimming is a suitable exercise for the lungs. Learning Objective Recognize that parental statements regarding a pediatric asthma client raking leaves indicate that additional parental education is needed. Additional Info Source : Archer Review Environmental allergen exposure is one of the most common causes of asthma exacerbation. Asthma triggers range from environmental allergens and respiratory irritants to infections, aspirin, exercise, emotion, and gastroesophageal reflux disease. Client education is key to avoiding asthma attack triggers. Last Updated - 19, Dec 2022

The nurse is completing an assessment on a 6-year-old client with asthma. Which of the following assessment findings is of most concern to the nurse? A. Expiratory wheezing B. Silent chest C. Cough D. Head bobbing Submit Answer

Explanation Choice B is correct. Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's airway and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the client has lost their airway. Choice A is incorrect. Expiratory wheezing is an expected finding when a client is having an asthma exacerbation. This occurs when there is inflammation in the airways and air trapping, making it hard for the client to fully exhale all of the air in their lungs. The wheezing is audible as they attempt to exhale. Although it is a significant finding, it is not the finding of most concern in this question, because the client still has a patent airway. Choice C is incorrect. A cough is an expected finding when a client is having an asthma exacerbation. This finding is not of most concern. Choice D is incorrect. Head bobbing is an indication of increased work of breathing in the pediatric client experiencing an asthma exacerbation. It occurs when the child's head moves forward each time they take a breath. This finding is significant and an indication that further support is needed, but it is not the priority. This is categorized under "B" for breathing, while there is another assessment finding falling under the "A" for airway which is the priority. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological adaptation, Pediatric - Respiratory Additional Info Source : Archer Review Last Updated - 19, Dec 2022

The RN is taking vital signs on an infant diagnosed with total anomalous pulmonary venous return (TAPVR) and then the mother starts crying. Which of the statements by the nurse is most therapeutic? A. "Don't cry, your baby will be fine!" B. "I can see you are upset. Sometimes it helps to talk about it." C. "I'm sure this is hard, but your baby is doing so well!" D. "You think this is bad, you should see some of the other babies here." Submit Answer

Explanation Choice B is correct. This is a good example of therapeutic communication. The nurse has validated the mother's feelings and encouraged further dialogue to understand what the mother is upset about. Choice A is incorrect. This is not a therapeutic statement. The nurse does not know that the baby will be fine and should not brush off the mother's concerns. Choice C is incorrect. This is not a therapeutic statement. The nurse should encourage further dialogue with the mother instead of pushing her concerns aside. Choice D is incorrect. This is not a therapeutic statement. It is not appropriate to compare the infant to other patients on the unit. Furthermore, this does not encourage conversation with the mother to help address her concerns. NCSBN Client Need Topic: Psychosocial Integrity; Subtopic: Pediatrics - Cardiac; communication Additional Info Source : Archer Review Last Updated - 20, Jan 2022

Which of the following is the nurse's priority nursing action for the infant experiencing a tetralogy of Fallot (tet) spell? A. Administer propranolol B. Administer sodium bicarbonate C. Calm the infant D. Notify the healthcare provider Submit Answer

Explanation Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take. Choice A is incorrect. While propranolol may be used in children with tetralogy of Fallot, it will not be the priority nursing action for the infant experiencing a tet spell. It will be given much later if necessary. Choice B is incorrect. Sodium bicarbonate may be needed at some point during a tet spell if it is not resolving, but would not be indicated as soon as it starts and would not be the priority nursing action. Choice D is incorrect. While the nurse will need to notify the healthcare provider of the spell and may need additional assistance, this still isn't the priority action. There is another action listed that will immediately help the infant and should be the priority. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic care, comfort, Pediatrics - Cardiac Last Updated - 19, Jan 2022

The nurse is performing a health assessment on a newborn. Which assessment finding would lead the nurse to suspect cystic fibrosis? A. Steatorrhea B. Hyperhidrosis C. Meconium ileus D. Barrel chest Submit Answer

Explanation Choice C is correct. Meconium Ileus is frequently the first sign of cystic fibrosis in a newborn. Meconium ileus is a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within a few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock. Choice A is incorrect. Steatorrhea is described as stools that are bulky, frothy, and foul-smelling. Steatorrhea is caused by the excretion of abnormal quantities of fat in the stool. This occurs in cystic fibrosis but is not present yet in a newborn. Choice B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not a sign of cystic fibrosis in the newborn. Newborns with cystic fibrosis will have elevated chloride levels in their sweat, causing it to taste salty, but they will not sweat excessively. Choice D is incorrect. Barrel chest is a long-term complication of cystic fibrosis but not a sign that would be present at birth in the newborn. A barrel chest is a broad, deep chest that is large and cylindrical. It occurs when the patient has been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time. Additional Info Cystic fibrosis is a multisystem disorder that is caused by a genetic defect. This disorder is inherited as an autosomal recessive trait. ➢ Meconium ileus is one of the earliest manifestations in a newborn with cystic fibrosis. This may occur within the first two weeks of life. Manifestations of a meconium ileus include abdominal distension and failure to pass meconium, with or without vomiting. Treatment includes nasogastric tube (NGT) insertion, which may decompress the abdomen. Last Updated - 06, Nov 2022

Which of the following are signs of decreased cardiac output in an infant with congenital heart disease? Select all that apply. A. Poor feeding B. Irritability C. Bradycardia D. Increased urine output Submit Answer

Explanation Choices A and B are correct. Poor feeding is often one of the first signs of decreased cardiac output in an infant. It becomes harder for the infant to breathe while feeding; they often become sweaty and pale during feedings. This is a classic sign of decreased cardiac output (Choice A). Irritability, restlessness, or lethargy are vital signs of decreased cardiac output in the infant (Choice B). Choice C is incorrect. Tachycardia, not bradycardia, would be a sign of decreased cardiac output. The body senses decreased perfusion and provides feedback to the heart to beat faster to make up for it. In doing so, the infant compensates for the decreased cardiac output for some time. Only after their body can no longer keep up will it progress to bradycardia. Choice D is incorrect. Decreased urine output would be a sign of decreased cardiac output. As the perfusion to the body lessens, blood is reserved for essential organs and the kidneys do not get as much blood flow; eventually leading to decreased urine output. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological Adaptation, Subtopic: Cardiovascular Last Updated - 26, Apr 2021

The nurse is working with a 17-year-old client diagnosed with cystic fibrosis. Which of the following is the most important for clients of this age with cystic fibrosis? A. Providing opportunities for the teen to learn about their condition. B. Facilitating interaction amongst peers. C. Promoting independence in decision making by including the patient in their care. D. Emphasizing the importance of education and remaining in school. Submit Answer

Explanation Choice C is correct. Promoting independence in decision-making by including the client in their care is the top priority for a 17-year-old with CF. They will soon be making the transition to adult doctors and teams and have a legal say in their treatment as an adult. Facilitating their independence is very important. Choice A is incorrect. By the time the child has reached adolescence they have been living with CF for many years and have already had many opportunities for the teen to learn about their condition. This is not the most important priority for a teenager with CF. Choice B is incorrect. Facilitating interaction amongst peers is important, but as a teenager, this patient will already have had a lot of experience interacting with their peers. This is not the most important priority for a teenager with CF, rather it would be a higher priority in school-age clients. Choice D is incorrect. Emphasizing the importance of education and remaining in school is not the most important priority for a teenager with CF. This client is 17 and has already been in school for over 10 years. The time to emphasize the importance of education as a top priority is in the school-age client and early teen years. The 17-year-old has another goal that is of higher priority. NCSBN Client Need: Topic: Psychosocial Integrity; Subtopic: Pediatric - Respiratory Last Updated - 27, Dec 2021

A nurse listens to a 2-year old's lungs and hears inspiratory stridor. After suspecting an upper airway obstruction, what is the nurse's first action? A. Tell the patient to cough to relieve the obstruction B. Apply a bag valve mask C. Perform the Heimlich maneuver D. Perform a blind finger sweep E. Place the patient in prone position Submit Answer

Explanation Choice C is correct. Since this patient has inspiratory stridor, the nurse can infer that the patient has an upper airway obstruction. Performing a blind finger sweep is not recommended. The nurse should only attempt a finger sweep if the object is visible. Performing the Heimlich maneuver should be the first action to relieve the obstruction. After that, if the patient's oxygenation is worsening, oxygen should be applied to the patient. Choice A is incorrect. This patient is too young and won't be able to cough up the obstruction. Choice B is incorrect. As explained above, oxygen can be given if the respiratory system starts to fail, but it should not be the first intervention performed. Choice D is incorrect. The nurse should never perform a blind finger sweep if the object is not visible. This could cause the object to become further dislodged in the airway. Choice E is incorrect. Placing the patient in a prone position is done on infants. NCSBN Client Needs Topic: Safe and Effective Care Environment, Sub-Topic: Care Management, Airway Obstruction Last Updated - 13, Jan 2022

An infant is admitted to the pediatric floor to rule out cystic fibrosis. The nurse assesses the infant's stool, concluding the stool is consistent with a diagnosis of cystic fibrosis. Which of the following would describe this infant's stool? A. Small, hard, pellet-like stool B. Green, malodorous stool C. Oily, odorous, bulky stool D. Loose, yellow stool Submit Answer

Explanation Choice C is correct. This disease process frequently affects the pancreas, intestines, and hepatobiliary systems, resulting in the malabsorption of fats, fat-soluble vitamins, and protein in 85 to 95% of cystic fibrosis patients. As a result, gastrointestinal manifestations include the frequent passage of bulky, foul-smelling, oily stools. Choice A is incorrect. Small, hard, pellet-like stools are not characteristic stools produced by cystic fibrosis clients. Choice B is incorrect. Malodorous bowel movements are a clinical manifestation of cystic fibrosis clients; however, these bowel movements are not traditionally described as "green" in color. Choice D is incorrect. Loose, yellow bowel movements are not traditionally associated with cystic fibrosis patients. Learning Objective Correlate oily, odorous, bulky bowel movements with cystic fibrosis clients. Additional Info Cystic fibrosis is an inherited disease affecting primarily the gastrointestinal and respiratory systems. While universal newborn screening for cystic fibrosis is now standard in the United States, it is important to note that this screening tool cannot diagnose cystic fibrosis alone. When a newborn screening returns a positive result, it is followed by a sweat test to confirm the diagnosis. Despite advances in genetic testing, the sweat chloride test remains the standard for confirming a cystic fibrosis diagnosis in most cases because of the test's sensitivity, specificity, simplicity, and availability. Although most cases of cystic fibrosis are first identified by newborn screening, up to 10% of those with cystic fibrosis are not diagnosed until adolescence or early adulthood. Last Updated - 09, Sep 2022

Which is a common finding when assessing cardiac status in preschool children? A. Noting a large discrepancy in arm and leg blood pressures. B. The point of maximal impulse (PMI) is at the fifth intercostal space (ICS), about 7-9 cm from the mid-sternum. C. Pulses are elevated when breathing in and decrease when breathing out. D. A systolic click best heard at the sternal border. Submit Answer

Explanation Choice C is correct. This finding indicates sinus arrhythmia, a commonly encountered variation of normal sinus rhythm. It is typically seen in children and young adults. During respiration, intermittent vagus nerve activation occurs, which results in beat-to-beat variations in the resting heart rate. When present, sinus arrhythmia typically indicates good cardiovascular health. Sinus arrhythmia is a commonly encountered finding when assessing preschool cardiac status. Choice A is incorrect. A large discrepancy in brachial and leg blood pressure readings may indicate congenital heart defects like coarctation of the aorta or other obstructive disorders. This is not a normal finding in preschool children and should be examined further. Choice B is incorrect. The point of maximal impulse (PMI) is the point where there is a maximum impulse against the chest that can be felt. It may also be seen in thin-chested clients when the client is lying flat. Most often, this is from the apex or tip of the heart and is also referred to as the apical impulse. In children, the PMI is located between the fourth and fifth intercostal spaces at the midclavicular line. Choice D is incorrect. A systolic click best heard at the sternal border may be associated with mitral insufficiency or a number of other cardiac concerns. This finding is not normal in children and should be evaluated further. Learning Objective Sinus arrhythmia is a commonly encountered variation of normal sinus rhythm frequently seen when assessing cardiac status in preschool children. Additional Info Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Generally, sinus arrhythmia is at most mildly symptomatic (e.g., palpitations) and warrants no specific treatment. From a practical standpoint, sinus arrhythmia must be differentiated from pathologic sinus pauses that may be responsible for more significant symptoms, such as syncope. Last Updated - 19, Jan 2023

The nurse is working with an advocacy group to raise awareness about cystic fibrosis. Which statement best explains the condition? A. "It is an inherited disease that causes inflammation and hypersensitivity of the airway." B. "It is an infectious disease causing inflammation and fluid accumulation in the alveoli of the lungs." C. "It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages." D. "It is an acquired disease that causes inflammation and swelling of the epiglottis." Submit Answer

Explanation Choice C is correct. This statement correctly describes cystic fibrosis as an inherited disease causing excessive, thick mucus to build up in the body and cause blockages. Choice A is incorrect. Cystic fibrosis is NOT an inherited disease that causes inflammation and hypersensitivity of the airway. A disease that causes inflammation and hypersensitivity of the airway is asthma, not CF. Choice B is incorrect. Cystic fibrosis is NOT an infectious disease that causes inflammation and fluid accumulation in the alveoli of the lungs. Pneumonia is an infectious disease that causes inflammation and fluid accumulation in the alveoli of the lungs. Choice D is incorrect. Cystic fibrosis is NOT an acquired disease that causes inflammation and swelling of the epiglottis. Epiglottitis is a disease that causes inflammation and swelling of the epiglottis. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological adaptation; Pediatric - Respiratory Last Updated - 22, Jan 2022

The RN is caring for a family who just found out that their newborn baby has tetralogy of Fallot. The parents state, "We can't believe our baby is going to die!" Which of the following statements by the RN is most appropriate? A. "Yes, that is so sad. What can I do to help you?" B. "Your baby will be fine! This is not so serious." C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect." D. "Well, at least you get to spend time with your baby now. Some people don't even get that." Submit Answer

Explanation Choice C is correct. This statement does not support that the baby will die, but provides factual information about the treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for these parents. Choice A is incorrect. This is not a therapeutic statement, as it is not necessarily true that the baby is going to die. The nurse should not validate this fear, rather the nurse needs to provide further education to help the family understand what to expect. Choice B is incorrect. The nurse should not invalidate the parent's fears. TOF is a very serious heart defect, so telling the parents that the baby will be fine may not be true. It is important to provide factual education to the parents so that they understand their child's cardiac defect. Choice D is incorrect. This statement is neither helpful nor accurate. The nurse should not say this. NCSBN Client Need Topic: Health promotion and maintenance; Subtopic: Pediatrics - Cardiac Last Updated - 10, Nov 2021

A nurse at the family clinic is educating the mother of a 13-year-old regarding how to avoid acute asthma attacks. Which statement, if made by the mother, indicates effective teaching? A. "Dogs and cats would be okay to have as a family pet." B. "I can take my daughter to the mountains to ski." C. "Swimming would be a good exercise for my daughter." D. "Cold weather may make symptoms better." Submit Answer

Explanation Choice C is correct. This statement made by the mother indicates effective teaching. Exercise is not contraindicated for those with asthma. Acceptable forms of exercise include low-intensity activities such as swimming, walking, and hiking. Choices A, B, and D are incorrect. Animal dander can trigger asthma attacks. The client must be reeducated to avoid pets, including, but not limited to, dogs, cats, and birds. Turtles, fish, and other pets without dander can be acceptable pets for children with asthma. Extreme cold is considered a nonallergenic trigger for an acute asthma attack. Snow skiing exposes the child to extreme cold, placing the child at risk for a severe asthma attack. Learning Objective Identify the client education topics a nurse should address with an asthmatic child's mother. Additional Info Source : Archer Review Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea, chest tightness, cough, and wheezing. Diagnosis is based on history, physical examination, and pulmonary function tests. Treatment involves controlling triggering factors and drug therapy, most commonly with inhaled beta-2 agonists and inhaled corticosteroids. Last Updated - 19, Dec 2022

The nurse is assessing a patient diagnosed with an atrioventricular canal. She knows that many infants with an atrioventricular canal also have a diagnosis of which of the following? A. Trisomy 18 B. Turner syndrome C. Trisomy 21 D. DiGeorge Syndrome Submit Answer

Explanation Choice C is correct. Trisomy 21, or Down's Syndrome, is commonly associated with an atrioventricular canal. Infants with trisomy 21 also commonly present with an atrial septal defect (ASD) or ventricular septal defect (VSD). Choice A is incorrect. Trisomy 18, or Edwards syndrome, is commonly associated with a VSD or hypoplastic left heart syndrome (HLHS), but not an atrioventricular canal. Choice B is incorrect. Turner syndrome is commonly associated with several different heart defects including a VSD, coarctation of the aorta (COA), aortic stenosis, and HLHS, but not an atrioventricular canal. Choice D is incorrect. DiGeorge Syndrome is commonly associated with an interrupted aortic arch, but not an atrioventricular canal. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Risk potential reduction, Pediatrics - Cardiac Last Updated - 23, Jan 2022

A mother brings her toddler to the pediatrician. Her child is on digoxin for congestive heart failure. The nurse tells the mother about signs of digoxin toxicity. Which statement by the mother would indicate an understanding of the topic? A. "I will have my son checked if his respirations are less than 20." B. "I will stop digoxin if my son does not gain any weight after 6 months." C. "I will avoid feeding him potassium rich food." D. "I will have the doctor see my son if he vomits." Submit Answer

Explanation Choice D is correct. Vomiting is an early sign of increased digoxin levels in the blood. The mother should bring her son to the doctor immediately to have his serum digoxin levels checked so that appropriate intervention can be initiated. Choice A is incorrect. A decreased respiratory rate is not associated with digitalis toxicity. A reduced heart rate is a sign associated with digitalis toxicity. Choice B is incorrect. Failure to thrive (FTT) is commonly associated with congestive heart failure. However, it is not associated with digitalis toxicity. The mother should also not discontinue any medications unless told by a doctor. Choice C is incorrect. The mother needs to serve high potassium foods to her child as a low potassium level will aggravate digitalis toxicity. Last Updated - 31, Jan 2022

When educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following are considered early signs of heart failure? Select all that apply. A. Diaphoresis B. Sudden weight gain C. No wet diapers D. Hypoxia Submit Answer

Explanation Choices A and B are correct. The parents of children with congenital heart defects need to be aware of the "early" signs of heart failure, so they can report them to the healthcare provider before it is too late. Diaphoresis (Choice A), or excessive sweating is a common early sign of heart failure. Parents should be taught to look out for excessive sweating, especially at rest. Sudden weight gain (Choice B) is due to fluid retention and edema. This indicates decreased cardiac output, increased venous congestion, and is an early sign of heart failure. Choice C is incorrect. An infant or child having "no wet diapers" would mean he/she is severely oliguric. Oliguria is due to decreased kidney perfusion that occurs during untreated heart failure. This degree of damage to the kidneys takes time and is a late sign of heart failure, not an early warning. Choice D is incorrect. Hypoxia is also a late sign of heart failure, not an early warning. Hypoxia is typically secondary to pulmonary edema that develops during untreated heart failure. Last Updated - 01, Feb 2022

There has been an increased incidence of SIDS in your hospital, and many of the new mothers delivering babies at your hospital are asking for more information about the syndrome. As a nurse on the Mother-Baby floor, you are placed in charge of creating a teaching handout for new mothers about SIDS prevention. It is important to include which of the following points? Select all that apply. A. 'Back-to-sleep' is the safest position for infants to sleep; place them supine in their crib for all naps and at night. B. Risk factors for SIDS include a hard crib mattress and hypothermia. C. Cigarette smoking in the house can be a risk factor, so all family members should be encouraged to quit. D. It is okay to leave stuffed animals and toys in the crib as long as they are away from the infant's face. Submit Answer

Explanation Choices A and C are correct. 'Back-to-sleep' is the safest position for infants to sleep and should be included in the teaching handout. Smoking is a known risk factor for SIDS, and family members should be given information to help them quit to prevent SIDS. Choice B is incorrect. There are many risk factors for SIDS. A soft mattress or bedding is a risk factor rather than a hard crib mattress. This is because if an infant rolls over onto his stomach and cannot turn back over, a soft mattress can suffocate them. A hard mattress will not conform to their face as quickly and be easier for them to breathe around. Hypothermia is also not a known risk factor for SIDS; however, slightly overheating and thermal stress can be a cause. Choice D is incorrect. It is not safe for stuffed animals and toys to be in the crib when the infant is asleep due to the risk of suffocation. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Alterations in Body Systems Last Updated - 25, Jan 2022

You are providing asthma education to a teen that has just been diagnosed with asthma. Which of the following statements indicate a need for further teaching? Select all that apply. A. "When I am having an asthma attack, I should call 911 first." B. "When I am having an asthma attack, my airway is constricting and it can become dangerous." C. "I should try to identify what causes me to have an asthma attack and avoid those activities." D. "I've really been wanting to get a dog and my asthma will not stop me." Submit Answer

Explanation Choices A and D are correct. These statements indicate a need for further education. During an asthma attack, the first action should not be to call 911. The patient will have an asthma action plan that lists the steps she should take in the order she should take them. For most patients, the first step is to take short-acting inhaler medications. It is not necessary to first call 911 for every asthma attack (Choice A). Although asthma will not stop every child from getting a dog, pets with hair that sheds can be a trigger. It would be inadvisable for a teen newly diagnosed with asthma to get a new dog. It could end up causing more asthma attacks and present a severe problem. If the patient wants a new pet, a fish would be a better recommendation given their new asthma diagnosis (Choice D). Choice B is incorrect. This is an appropriate statement and does not indicate a need for further education. When a patient is having an asthma attack, the physiology includes inflammation and constriction of the airways. This can result in obstruction, making it impossible for the patient to breathe. That is why asthma attacks are so dangerous. Choice C is incorrect. This is an appropriate statement and does not indicate a need for further education. One of the most critical educational points for patients newly diagnosed with asthma is identifying their triggers. Triggers are what precipitate an asthma attack for that patient. For example, maybe playing soccer, or dusting the house. Whatever it is that precipitates their asthma should be avoided. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory Last Updated - 11, Nov 2021

You are providing discharge teaching for a 3-year-old patient with CHF. She is going home on digoxin. Which instructions are essential to teaching her parents regarding the administration of this medication? Select all that apply. A. Administer digoxin one hour before or two hours after meals. B. Mix the medication with milk or applesauce to ensure she drinks it all. C. If the child vomits after administering a dose then repeat the dose. D. Call the doctor if the child starts eating poorly and vomiting frequently. Submit Answer

Explanation Choices A and D are correct. This is the appropriate instruction to ensure proper absorption of digoxin. It is best to advise the parents to create a schedule and administer it at the same time each day, often before breakfast in the morning (Choice A). Poor feeding and frequent vomiting are signs of digoxin toxicity. This should be taught to the parents at discharge so that they can monitor their child for these symptoms and call the health care provider if they occur. This is the result of a timely lab test to determine the serum digoxin level and early treatment if toxicity has occurred (Choice D). Choice B is incorrect. This is not an appropriate action when administering digoxin. For the medication to be absorbed correctly, it must be taken on an empty stomach. Never administer digoxin with food. Choice C is incorrect. This is not an appropriate action when administering digoxin. A second dose should not be delivered, even if the child vomited after their first dose. Digoxin toxicity is severe and overdosing the child should always be avoided. Due to the potential toxicity, it is not advisable to administer a second dose, even if the child vomited. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Cardiovascular Last Updated - 11, Feb 2022

While reviewing congenital heart defects with a senior nurse in the PICU, she asks you which errors have increased pulmonary blood flow. You respond by listing which of the following? Select all that apply. A. Atrial septal defect (ASD) B. Atrioventricular canal defect C. Ventricular septal defect (VSD) D. Aortic stenosis Submit Answer

Explanation Choices A, B, and C are correct. An ASD is an abnormal opening between the atria. It causes an increased flow of oxygenated blood into the right side of the heart, which therefore increases pulmonary blood flow. An atrioventricular canal defect (AV canal) is the incomplete fusion of the endocardial cushions leading to an open 'canal' between both atriums and ventricles. Oxygenated and deoxygenated blood mix in the open canal and cause increased pulmonary blood flow. A VSD is an opening between the two ventricles. Blood shunts from the left ventricle where there is higher pressure and then to the right ventricle where there is lower pressure, causing the increased pulmonary blood flow. Choice D is incorrect. Aortic stenosis is the narrowing of the aortic valve. This causes resistance to systemic blood flow and is characterized as an obstructive congenital heart defect. It does not create increased pulmonary blood flow. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Alterations in Body Systems Last Updated - 09, Jan 2021

Which of the following educational points would be helpful for optimizing feedings in an infant with heart failure? Select all that apply. A. Small frequent feedings B. Feeding every 5 hours C. Feed for a maximum of 30 minutes D. Increased calorie formula Submit Answer

Explanation Choices A, C, and D are correct. A is correct. It is appropriate advice to feed an infant with heart failure in small, frequent feedings. These infants will have a difficult time feeding and are working very hard during their feeds. They will need to be paced so that they conserve their energy and do not burn too many calories while feeding. Small, frequent feeds are the best way to optimize their nutrition. C is correct. It is appropriate advice to feed an infant with heart failure for only 30 minutes at a time. After 30 minutes of feeding, the infant is using too much energy to gain calories and grow due to the feeding. Conserving energy is very important for infants experiencing heart failure. D is correct. It is appropriate advice to feed an infant with heart failure an increased calorie formula. This will allow them to get a maximum amount of calories for growth in as little work as possible. Infants who are breastfed may require additional supplementation to grow. Choice B is incorrect. Feeding an infant with heart failure every 5 hours is not frequent enough. Small, frequent feedings should be initiated to maximize caloric intake and conserve energy. A baby with heart failure should be fed on a schedule every 3 hours. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Cardiac Last Updated - 11, Jan 2022

Which of the following signs and symptoms are indicative of cystic fibrosis? Select all that apply. A. Steatorrhea B. Hypernatremia C. Meconium ileus D. Salty sweat Submit Answer

Explanation Choices A, C, and D are correct. A is correct. Steatorrhea is a symptom of CF. Steatorrhea is fatty, frothy stools. This is due to the malabsorption of fat. In CF, the body produces thick, sticky mucus that clogs up the body. The body is unable to absorb many things, including fat. Due to this, fat passes through the digestive tract without being absorbed and is excreted in the form of steatorrhea. C is correct. Meconium ileus is a symptom of CF. It is often the first sign of CF in an infant. Meconium ileus is when a newborn is unable to pass their first stool (meconium). In CF, this is because the thick, sticky mucous has clogged up the body and made it difficult for the infant to pass their first stool. D is correct. Salty tasting sweat is a symptom of CF. These children lose a large amount of sodium in their sweat, making their sweat taste salty. It puts them at risk for hyponatremia and is one of the first things parents might notice about their infant born with CF. Choice B is incorrect. CF patients are at risk for hyponatremia, not hyper. This is due to sweating excessive amounts of sodium out of their body. They lose so much sodium in their sweat that they have low serum sodium levels (hyponatremia). NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Pediatrics - Respiratory Last Updated - 15, Feb 2022

Which of the following are true regarding aortic regurgitation in a pediatric client with complex congenital heart disease? Select all that apply. A. Aortic regurgitation increases preload in the left ventricle. B. Aortic regurgitation leads to a systolic murmur. C. Aortic regurgitation causes decreased cardiac output. D. Aortic regurgitation increases left ventricle end diastolic pressure. Submit Answer

Explanation Choices A, C, and D are correct. With aortic regurgitation, during diastole, there is a backward flow of blood from the aorta into the left ventricle. The blood should be moving forward into the systemic circulation, but when the heart relaxes, there is a small amount of 'regurgitation,' and the blood trickles back to where it came from. With this increased amount of blood flowing back into the left ventricle, there is increased preload in the left ventricle (A is correct), a decrease in cardiac output (C is correct), and an increased left ventricular end-diastolic pressure (D is correct). Choice B is incorrect. Aortic regurgitation does not cause a systolic murmur but rather a diastolic murmur. The blood backflows across the aortic valve when the heart relaxes during diastole, causing a diastolic murmur. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological Adaptation Last Updated - 02, Nov 2021

Which of the following are considered early signs of heart failure in a pediatric patient? Select all that apply. A. Bradycardia B. Tachypnea C. Diaphoresis D. Weight loss Submit Answer

Explanation Choices B and C are correct. Tachypnea is an early sign of heart failure. The child's body is working hard to compensate for the decrease in cardiac output, so they breathe more quickly to try and make up for the decreased oxygen delivery (Choice B). Diaphoresis is a ubiquitous sign of heart failure, especially in the infant. The child's body is fatigued as it works hard, trying to compensate for the decreased cardiac output. Therefore they sweat profusely during exertion and sometimes even at rest (Choice C). Choice A is incorrect. Bradycardia is a late and ominous sign of heart failure. Tachycardia is an early sign of heart failure. Due to the decrease in cardiac output, the child's body compensates and increases the heart rate to try to keep up. This is why tachycardia is an early sign of heart failure. Choice D is incorrect. Weight gain rather than weight loss would be an early sign of heart failure. The child's body will be retaining fluids as the perfusion to their kidneys decreases. When kidney function starts to decline, such as in early heart failure, then there will be a sudden weight gain. NCSBN Client Need Topic: Physiological Integrity Subtopic: Physiological Adaptation, Cardiovascular Last Updated - 31, Oct 2021

Which of the following signs are indicative of heart failure in an infant? Select all that apply. A. Weight loss B. Tachycardia C. Diaphoresis D. Fatigue Submit Answer

Explanation Choices B, C, and D are correct. Tachycardia is a sign of heart failure. The heart is not pumping effectively and the cardiac output is therefore decreasing. The infant's body notices a decrease in oxygen delivery to the tissues and increases the heart rate to compensate for the decreasing cardiac output. This is why tachycardia is a sign of heart failure (Choice B). Diaphoresis is a sign of heart failure. Infants will become very sweaty when they are in heart failure; you can notice this especially on their scalp, where healthy babies would not usually sweat. They are diaphoretic because their body is working hard to compensate for the decrease in cardiac output due to heart failure (Choice C). Fatigue is common in heart failure (Choice D) due to the decreased cardiac output and thereby, reduced oxygen delivery to the tissues. The infant's body demands more oxygen and heart failure makes it difficult to keep up with the demand, so they get very fatigued. Choice A is incorrect. Weight gain, not loss, is a sign of heart failure in an infant. For infants experiencing heart failure, their hearts will not be pumping blood effectively. This means that fluid is not moving forward and blood is backing up in the body. This backup of blood leads to many complications, one of which is weight gain. When there are sudden weight changes, think fluid, not fat. Fluid changes most often are caused by cardiac problems. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Pediatrics - Cardiac Last Updated - 30, Jan 2022

The nurse is developing a plan of care for a client diagnosed with Kawasaki disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Initiate contact precautions B. Obtain a 12-lead electrocardiogram C. Offer soft foods and liquids D. Implement fluid restriction E. Administer aspirin, as prescribed Submit Answer

Explanation Choices B, C, and E are correct. Kawasaki disease is an autoimmune disorder that occurs primarily in individuals younger than five. This disease process may consequently cause inflammation of the coronary arteries leading to aneurysms. Thus, an electrocardiogram should be performed along with an echocardiogram. Soft foods and liquids should be offered because of the chapping of the lips. Fluids would be encouraged because of the fever commonly associated with Kawasaki disease. Finally, treatment for this disease includes either medium to high dose aspirin or intravenous immunoglobin. Choices A and D are incorrect. Kawasaki disease is an inflammatory condition causing systemic vasculitis. Thus, standard precautions are applicable for this disease. Fluid restrictions are not helpful in an individual with Kawasaki disease, and the nurse should encourage more fluids because of the fever associated with this syndrome. Additional Info Kawasaki disease is an inflammatory syndrome commonly found in individuals younger than five, affecting males more than females. Classic symptoms include fever, chapped lips, bilateral conjunctivitis, and polymorphous rash. Prompt treatment with aspirin or intravenous immunoglobin is needed to prevent injury to the coronary arteries. It is important to note that Kawasaki disease is the one time that aspirin is administered in the pediatric population. Usually, it is avoided due to the risk of Reye's syndrome. However, Kawasaki disease is the exception to this rule, and aspirin is routinely used in this case. Last Updated - 07, Feb 2022

When evaluating the heart rate of a 2-year-old patient that is awake, the nurse documents which of the following heart rates as tachycardia? Select all that apply. A. 60 beats per minute B. 130 beats per minute C. 150 beats per minute D. 180 beats per minute Submit Answer

Explanation Choices C and D are correct. The average heart rate for a 2-year-old when awake is 100 to 130. So, the nurse would document heart rates of 150 (choice C) and 180 (choice D) as tachycardia. Tachycardia in an infant/ toddler may indicate fever, illness, pain, dehydration, anxiety, or stress. Since pediatric vitals differ from adult vitals, it is essential for the nurse to be aware of the normal vitals in children so the nurse can plan appropriate interventions should the vitals turn out abnormal. Choices A and B are incorrect. The average heart rate for a 2-year-old is 100 to 130. The nurse would document a heart rate of 60 (choice A) as bradycardia, not tachycardia. The nurse would enter a heart rate of 130 (choice B) as expected, not tachycardia. Learning Objective Recognize that pediatric vital signs differ from adults and know the age-based normal ranges. Additional Info Source : Archer ReviewSource : Archer Review Last Updated - 12, Jan 2023

While working in a pediatric cardiac intensive care unit, you are caring for a child diagnosed with tetralogy of Fallot. Upon entering the room in the morning for your first assessment you find the child crying, cyanotic, and tachycardic. You recognize this as a hypercyanotic tet spell. Place the following actions in order of priority: -Administer 100% oxygen -Place the infant in the knees to chest position -Administer an IV fluid bolus -Administer morphine sulfate -Document the event Document the event Administer 100% oxygen Administer morphine sulfate Administer an IV fluid bolus Place the infant in the knees to chest position Submit Answer

Explanation Correct answer: The priority in a hypercyanotic tet spell is to place the child in a knee to chest position. Tet spells occur when the infant with tetralogy of Fallot becomes acutely cyanotic due to infundibular spasm usually associated with feeding or crying. When this spasm occurs, there is decreased flow from the right ventricle due to the obstruction, resulting in severe hypoxia. Putting the child in a knee-chest position increases the intrathoracic pressure and increases blood flow to the lungs, therefore increasing oxygenation to body tissues. The next priority action is to administer 100% oxygen to assist in meeting the child's oxygenation requirements and relieving the hypoxia quickly. The following priority action is to administer morphine sulfate. This is the drug of choice for tet spells because it helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and, therefore, the hypercyanotic tet spell. The next priority nursing action is to administer an IV fluid bolus. This increases preload and consequently, cardiac output, helping to increase perfusion and oxygenation to the tissues. Lastly, the nurse should document the event, actions taken, and the patient's response. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Pharmacological and Parenteral Therapies, Cardiovascular Last Updated - 03, Nov 2021