Chapter 41: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

A pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can do to reduce the risk of this type of condition occurring in her baby. What information should the nurse mention to this client? A. "Make sure you are fully immunized." B. "There is really nothing you can do." C. "Make sure you encourage a low-sodium diet in your child as he grows up." D. "Make sure that you encourage your child to exercise as he grows up."

A. "Make sure you are fully immunized." The cause of congenital heart disease often cannot be documented, although it is associated with familial patterns of inheritance and possibly triggers such as rubella (German measles) and varicella (chickenpox) infection during pregnancy. Women need to enter pregnancy fully immunized to help prevent infection during pregnancy. Encouraging the child to eat a low-sodium diet and exercise as he or she grows up will help prevent acquired heart disease, not congenital heart disease.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed? A. "We can stop the penicillin when her symptoms disappear." B. "If she needs dental surgery, we might need additional medication." C. "She needs to take the drug for the full 14 days." "To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years."

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

The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply. A. "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." B. "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." C. "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." D. "It's wonderful that our child will never have an abnormal heart rhythm again." E. "Our child will be so excited to get back to soccer league in a few days."

A. "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." B. "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." C. "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." With the Gore® Helex device, strenuous activity should be avoided for 2 weeks after the procedure, so neither soccer or bicycle riding would be allowed. Children should be monitored for the possible presence of atrial arrhythmias (lifelong) after surgical closure for the defect. Infection is a complication that must be monitored for and reported to the physician, and medications must be given as prescribed.

The child has returned to the nurse's unit following a cardiac catheterization. The insertion site is located at the right groin. Peripheral pulses were easily palpated in bilateral lower extremities prior to the procedure. Which finding should be reported to the child's physician? Select all that apply. A. The child has a temperature of 102.4° F (39.1° C). B. The child has a runny nose C. the right groin is soft without edema D. the child is reporting nausea E. the child's right foot is cool with a pulse assessed only with the use of a Doppler

A. The child has a temperature of 102.4° F (39.1° C). D. the child is reporting nausea E. the child's right foot is cool with a pulse assessed only with the use of a Doppler The following information should be reported to the physician following a cardiac catheterization because they are indicative of possible complications: Negative changes to the child's peripheral vascular circulatory status (cool foot with poor pulse), a fever over 100.4° F (37.8° C), and nausea or vomiting.

A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse? A. These wires are connected to the heart and will detect if your infant's heart gets out of rhythm. B. The wires are left in the heart for 1 month after surgery in case of potential arrhythmias. C. The wires are measuring the fluid level in the heart. D. The wires will administer ongoing electrical shocks to the heart to maintain rhythm.

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

What information would be included in the care plan of an infant in heart failure? A. begin formulas with increased calories B. encourage larger, less frequent feedings C. administer digoxin even if the infant is vomiting D. maintain the child in the supine position

A. begin formulas with increased calories Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect? A. the child will need the BP checked two more times B. advise the child go to the ER C. the child will probably need surgery D. this is a normal result for a child this age

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

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. What would the nurse expect to find? Select all that apply. A. tiring easily when eating B. shortness of breath when playing C. cracks on lung auscultation D. bradycardia E. hypertension

A. tiring easily when eating B. shortness of breath when playing C. cracks on lung auscultation Manifestations of heart failure include difficulty feeding or eating, becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.

The nurse is caring for children at a local hospital. Which child warrants immediate attention from the nurse? A. 2-year-old child with clubbing noted on the fingers B. 1-week-old newborn whose oxygenation is not improving with oxygen C. 6-month-old infant with edema on the face and presacral area D. 1-year-old child with a temporal temperature of 101°F (38.3°C)

B. 1-week-old newborn whose oxygenation is not improving with oxygen A newborn whose oxygenation is not improving with oxygen warrants immediate attention. Congenital heart disease needs to be suspected in the cyanotic newborn who does not improve with oxygen administration. In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. This is an abnormal assessment finding that warrants follow-up but does not warrant immediate action. Clubbing is also an abnormal finding and warrants follow-up but not immediate action. It implies chronic hypoxia due to severe congenital heart disease. A temporal temperature of 101°F (38.3°C) is an abnormal assessment finding and warrants follow-up but not immediate action. Fever would suggest a possible infection.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? A. Furosemide B. Digoxin C. Alprostadil D. Indomethacin

B. Digoxin

The nurse performs a cardiac assessment and notes a loud heart murmur with a precordial thrill. This murmur would be classified as a: A. Grade I B. Grade IV C. Grade III D. Grade II

B. Grade IV A heart murmur characterized as loud with a precordial thrill is classified as Grade IV. Grade II is soft and easily heard. Grade I is soft and hard to hear. Grade III is loud without thrill.

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works? A. A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy B. High-frequency sound waves are directed toward the heart C. X-rays are directed toward the heart D. A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video

B. High-frequency sound waves are directed toward the heart Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. An echocardiogram involves high-frequency sound waves, directed toward the heart, being used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers; thickness of walls; relationship of major vessels to chambers; and the thickness, motion, and pressure gradients of valves. You can remind parents that echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

The nurse is caring for a child who is preparing to undergo an exercise stress test. Which interventions will be included in the care? Select all that apply. A. Complete ECG one hour after test is completed. B. Monitor vital signs at completion of the test. C. Assess blood glucose level prior to the start of the test and one hour after. D. Monitor vital signs prior to the start of the test. E. Remind the child to verbalize any feelings of discomfort during the test.

B. Monitor vital signs at completion of the test. D. Monitor vital signs prior to the start of the test. E. Remind the child to verbalize any feelings of discomfort during the test. The exercise stress test monitors heart rate, blood pressure, ECG, and oxygen consumption at rest and during exercise. Vital signs are taken prior to, during, and after the test period. An ECG is taken prior to the test. Serum glucose levels are not associated with this test.

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: A. narrow pulse B. femoral pulse weaker than brachial pulse C. hepatomegaly D. bounding pulse

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

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority? A. place the child on a soft diet B. initiate IV access C. assess cervical lymph nodes D. Administer acetaminophen

B. initiate IV access A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later.

A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child? A. hands B. lower extremities C. presacral region D. face

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

A health care provider and other health team members are discussing congenital heart disorders that increase pulmonary blood flow. Which disorders are topics for this discussion? Select all that apply. A. coarctation of the aorta B. ventricular septal defect C. patent ductus arteriosus D. pulmonary stenosis E. atrioventricular canal defect

B. ventricular septal defect C. patent ductus arteriosus E. atrioventricular canal defect Congenital heart defects classified as disorders with increased pulmonary blood flow include ventricular septal defect, patent ductus arteriosus, and atrioventricular canal defect. Pulmonary stenosis and coarctation of the aorta are classified as disorders with obstruction to blood flow.

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction? A. abdominal distress B. wheezing C. stomach upset D. nausea with diarrhea

B. wheezing The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset, nausea, and abdominal distress are common with oral antibiotics and do not need to be reported immediately.

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse? A. "This is something we should talk with the physician about. Maybe it would help your baby." B. "Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." C. "While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." D. "I can only place oxygen on your child if the doctor orders oxygen."

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

The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level? A. Ferrous sulfate B. Spironolactone C. Digoxin D. Albuterol sulfate

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

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease? A. feed on schedule every 4 hours to promote rest B. assess weight gain monthly C. breastfeed with small, frequent feeds D. ensure output of a minimum of 5 wet diapers daily

C. breastfeed with small, frequent feeds Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily. Feeding every 4 hours will not promote the intake and growth required for an infant with CHD.

A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia? A. increased WBC B. decreased WBC C. increased RBC D. decreased RBC

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

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching? A. "We need to avoid a tub bath for the next 3 days." B. "Strenuous activity should be limited for the next 3 days." C. "We need to watch for changes in skin color or difficulty breathing." D. "The feeling of the heart skipping a beat is common."

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

An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply? A. Ineffective airway clearance related to altered pulmonary status B. Impaired gas exchange related to a right-to-left shunt C. Impaired skin integrity related to poor peripheral circulation D. Ineffective tissue perfusion related to inefficiency of the heart as a pump

D. Ineffective tissue perfusion related to inefficiency of the heart as a pump A ventricular septal defect permits blood to flow across an opening between the right and left ventricles. It results in increased pulmonary blood flow, but it does not cause cyanosis. The blood in the left ventricle, which flows back into the right ventricle, is already oxygenated. Anytime there is an opening between the heart's ventricles, the heart is not as effective as a pump because the pressure gradients are changed. A ventricular septal defect will not cause respiratory problems or problems with peripheral circulation.

Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? A. fluid overload risk B. acute parental anxiety C. surgical site infection risk D. altered cardiopulmonary tissue perfusion risk

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

The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first? A. prepare for balloon angioplasty B. contact the HCP C. apply appropriate oxygen device D. assess BP in all extremities

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

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection? A. record pedal pulses B. apply EMLA cream to the catheter insertion site C. keep the child NPO for 2-4 hours before the procedure D. avoid drawing a blood specimen from the right femoral vein before the procedure

D. avoid drawing a blood specimen from the right femoral vein before the procedure Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention? A. elevate the head of the bed B. observe vitals Q2 C. administer epinephrine D. notify the doctor immediately

D. notify the doctor immediately The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? A. low BP and decreased HR B. Irritability and dry mucous membranes C. decreased HR and impalpable pulse D. peeling hands and feet; fever

D. peeling hands and feet; fever Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease. The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? A. anemia B. leukopenia C. increased platelet level D. polycythemia

D. polycythemia Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated. Leukopenia, increased platelets, and anemia are not associated with tetralogy of Fallot.