Pediatric Nursing - Cardiac Disorders
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond?
"Maternal antibodies interfere with the development of active antibodies by the infant when immunize
A nurse is caring for an infant who is experiencing heart failure. Which of the following would be the most appropriate care for this infant? a) Administer oxygen. b) Restrict fluids. c) Provide large, less frequent feedings. d) Administer antidiuretic.
Administer oxygen.
Which of the following would be included in discharge teaching by the nurse of a child that had a patch placed surgically for an ASD? a) Antibiotics should be administered before invasive procedures. b) Need for frequent rest periods at home c) Intake of 80 ounces of fluid daily d) Teaching about how to take daily blood pressures
Antibiotics should be administered before invasive procedures.
What is the priority nursing action when a 3-month-old infant is receiving intravenous (IV) fluids by way of an antecubital vein?
Applying arm boards to prevent bending at the elbows
A group of nurses is reviewing the cardiovascular system and its function. Which of the following statements is the most accurate regarding the cardiovascular system in the child? a) At birth the right and left ventricle are about the same size. b) Between the ages of 5 and 6 the left ventricle grows to about two times the size of the right. c) The heart rate of the child decreases if the child has a fever. d) The heart matures and functions like an adult's between 12 and 15 years of age.
At birth the right and left ventricle are about the same size.
A nurse teaches the parents of a 1-year-old infant that the primary developmental milestone to be accomplished between 12 and 15 months of age is the ability to:
Correct1 Walk erect
A 3-month-old infant is admitted to the pediatric unit with a diagnosis of tetralogy of Fallot. The nurse's infant's weight has declined from the 25th percentile to the 5th. The nurse concludes that the most likely reason for this inadequate weight gain is:
Correct4 Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
What is the nurse's priority concern when caring for an infant born with exstrophy of the bladder?
Development of an infection
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? a) Indomethacin b) Digoxin c) Furosemide d) Alprostadil
Digoxin
An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?
Exposing the casted extremity
After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
It is a connection between the pulmonary artery and the aorta.
A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change:
each week
A nurse is caring for a 3-month-old infant with congenital hypothyroidism. What should the parents be taught about the probable effect of the condition on the infant's future if treatment is not begun immediately?
Cognitive impairment
An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? (Select all that apply.
Fever Stiff neck Poor feeding
A nurse is administering digoxin to a 3-year-old. Which of the following would be a reason to hold the dose of digoxin? a) Hypertension b) Fever and tinnitus c) Nausea and vomiting d) Ataxia
Nausea and vomiting
When reviewing the record of a child with tetralogy of Fallot, which of the following would you expect to discover? a) Polycythemia b) Anemia c) Leukopenia d) Increased platelet level
Polycythemia
An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube?
"The tube has been placed to drain the air that entered the chest cavity during surgery."
A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?
Polycythemia
The mother of a 3-month-old infant asks the nurse in the well-baby clinic what toys to give her child. What is the nurse's response? (Select all that apply.)
-metallic mirror -colorful mobile
A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents?
Obtain a specially designed car seat.
Which behavior does the nurse expect when observing a 5-month-old infant?
Picking up a toy and putting it in the mouth
An infant is found to have hydrocephalus. Which finding alerts the nurse to suspect increasing intracranial pressure?
Projectile vomiting
A 6-week-old infant is brought to the clinic by the parents. The mother states that the baby has been vomiting with increasing frequency and force after feeding. Hypertrophic pyloric stenosis (HPS) is diagnosed by the practitioner. What clinical findings of HPS does the nurse expect to identify? (Select all that apply.)
White vomitus Peristaltic waves Insatiable hunger
The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding? a) Softening of the nail beds b) Intact rooting reflex c) Steady weight gain since birth d) Appropriate mastery of developmental milestones
Softening of the nail beds
The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postoperative positioning that helps prevent pressure on the valve site. What statement indicates that they understand the teaching?
"The flat left side-lying position is the safest position for our baby."
A nurse reviews with the parents of a young infant the principles of growth and development. Place the milestones in the order of their usual achievement.
1.Sits momentarily without support and rolls over 2.aves bye-bye and sits alone 3.Walks alone and builds a tower of two blocks 4.Climbs stairs and drinks from a cup 5. Draws a vertical line and walks on tiptoe
Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure?
Allow the infant to rest before feeding. Feed slowly while allowing time for adequate periods of rest.
A nurse is teaching a parent about the behaviors that are first evident in an infant at 8 months of age. What should the nurse include? (Select all that apply.)
Being shy with strangers Showing interest in small objects
A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? (Select all that apply.)
Fetal iron reserves are depleted Food can be taken from a spoon.
The parents of an infant who just underwent insertion of a ventriculoperitoneal shunt for hydrocephalus are concerned about the prognosis. What information should the nurse give the parents?
The shunt may need to be replaced as the child grows older.
A nurse is planning to evaluate the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?
There is an obstruction above the opening of the common bile duct.
A nurse is caring for an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular observation cannot be performed while the cast is in place?
pulse
Tetralogy of Fallot consists of the following four anomalies: aortic stenosis, atrial septal defect, dextroposition (overriding) of the aorta, and hypertrophy of the left ventricle. a) False b) True
False
A severely dehydrated infant admitted to the pediatric unit is too lethargic to receive oral rehydration therapy, and an intravenous infusion is started. What is the nurse's primary responsibility?
Monitoring the prescribed rate of flow
The nurse is caring for a 5-year-old child with a congenital heart anomaly causing chronic cyanosis. When performing the history and physical examination, what is the nurse least likely to assess? 1. Obesity from overeating. 2. Clubbing of the nail beds. 3. Squatting during play activities. 4. Exercise intolerance.
Obesity from overeating.
A 6-month-old infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Haemophilus influenzae type B (Hib) and pneumococcal conjugate vaccine (PCV). How should the nurse respond?
PCV and Hib are given together to protect against viral and bacterial diseases
A child is diagnosed with tetralogy of Fallot and during a temper tantrum turns blue. Which of the following would the nurse do first? a) Assess for an irregular heart rate. b) Assess for an increased respiratory rate. c) Place child in the knee-to-chest position. d) Explain to the child the need to calm down since it is affecting the heart.
Place child in the knee-to-chest position.
The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority? a) Use a calm, comforting approach. b) Administer propranolol (0.1 mg/kg IV). c) Provide supplemental oxygen. d) Place the child in a knee-to-chest position.
Place the child in a knee-to-chest position.
Which of the following would be most important to implement for an infant who develops heart failure? a) Placing her in a semi-Fowler's position b) Keeping her supine and playing quiet games c) Planning ways to reduce salt intake d) Restricting milk intake daily
Placing her in a semi-Fowler's position
A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that should be included in the discharge teaching plan for the mother?
Signs of dehydration in infants
A 5-month-old child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Prevention of what behavior is a priority for the nurse after the surgery?
Straining at stool
A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion?
The mother says the infant stopped making verbal sounds about a month ago.
A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision?
The newborn is being allowed to die.
A nurse is interviewing a mother who is about to deliver her baby. Which of the following responses would alert the nurse for a higher potential for a heart defect in the infant? a) The mother has seizures, but did not take medication while pregnant. b) The mother states she slept all the time while pregnant. c) The mother states she took acetaminophen while pregnant. d) The mother states she has lupus.
The mother states she has lupus.
The nurse is providing preoperative teaching to the parents of a 9-month-old infant who is having surgery to repair a ventricular septal defect. Identify the area of the heart where the defect is located.
A ventricular septal defect is a hole in the septum between the ventricles. The defect can be anywhere along the septum but is most commonly located in the middle of the septum.
A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note? a) Appropriate mastery of developmental milestones b) Pitting periorbital edema c) Bounding pulse d) Preference to resting on the right side
Bounding pulse
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. Which of the following is the best response from the nurse? a) It will determine disturbances in heart conduction. b) It will show if blood is being shunted. c) This image will clarify the structures within the heart. d) It will determine if the heart is enlarged.
It will determine if the heart is enlarged.
An infant with Tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
Knee-chest
A neonate was admitted to the pediatric unit with an unexpected congenital defect. What's the best way to involve the parents in the infant's care?
Offer the parents opportunities to be involved with the infant's care while they adjust to his unexpected condition.
A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time?
Providing formula thickened with cereal
A parent brings an infant in for poor feeding. Which of the following assessment data would most likely indicate a coarctation of the aorta? a) Pulses weaker in upper extremities compared to lower extremities b) Cyanosis with feeding c) Pulses weaker in lower extremities compared to upper extremities d) Cyanosis with crying
Pulses weaker in lower extremities compared to upper extremities
A nurse is caring for a 3-month-old infant who was admitted to the pediatric unit with severe dehydration caused by diarrhea. After fluid and electrolyte balance is restored, Lactobacillus granules (Lactinex) are prescribed. The nurse expects this medication to:
Recolonize flora in the intestinal tract
A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent? a) This is a test that will check how blood is flowing through the heart. b) This is a test that will check the electrical impulses in the heart. c) This test can only determine the size of the heart. d) This test is an invasive test that will measure the blockage in the heart.
This is a test that will check how blood is flowing through the heart.
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) Shortness of breath when playing b) Bradycardia c) Crackles on lung auscultation d) Hypertension e) Tiring easily when eating
• Tiring easily when eating • Shortness of breath when playing • Crackles on lung auscultation
You take an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant? a) 150 beats per minute b) 60 beats per minute c) 80 beats per minute d) 100 beats per minute
100 beats per minute
n intravenous line is inserted in the scalp vein of an infant. The mother asks why the IV is not placed in the hand or arm as for an adult. How should the nurse respond?
"Usually veins in the arm or hand are used, but your baby's were too small."
Which of the following would be included in the care of an infant in heart failure? a) Begin formulas with increased calories. b) Encourage larger, less frequent feedings. c) Maintain child in the supine position. d) Administer digoxin even if the infant is vomiting
Begin formulas with increased calories.
When caring for a child that has just had a cardiac catheterization, which of the following would indicate a sign of hypotension? a) Diaphoresis and tachycardia b) Cold clammy skin and increased heart rate c) Syncope and tachypnea d) Decreased heart rate and dizziness
Cold clammy skin and increased heart rate
A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy12-month-old infant?
29% to 41%
Coarctation of the aorta demonstrates few symptoms in newborns. Which of the following is an important assessment to make on all newborns to help reveal this condition? a) Recording an upper extremity blood pressure b) Observing for excessive crying c) Auscultating for a cardiac murmur d) Assessing for the presence of femoral pulses
Assessing for the presence of femoral pulses
A newborn with an anorectal anomaly undergoes anoplasty performed. At the 2-week follow-up visit, a series of anal dilations is started. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?
Breastfeed if possible.
An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect the health care provider to identify during the physical assessment?
Limited abduction of the affected hip
A nurse suspects a child is experiencing cardiac tamponade after heart surgery. Which of the following would be the priority nursing intervention? a) Observe vitals every two hours. b) Notify the doctor immediately. c) Administer epinephrine. d) Elevate the head of the bed.
Notify the doctor immediately.
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse evaluate the infant?
Tachycardia
A nurse is caring for a child who is experiencing heart failure. Which of the following assessment data was most likely seen when initially examined? a) Polyuria b) Tachycardia c) Bradycardia d) Splenomegaly
Tachycardia
At 3 years of age, a child has a cardiac catheterization. After the procedure, which of the following interventions would be most important? a) Allowing the child to talk about the procedure b) Allowing the child to adapt to the light room gradually c) Taking pedal pulses for the first 4 hours d) Assuring the child that the procedure is now over
Taking pedal pulses for the first 4 hours
A newborn has been diagnosed with a congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis? a) Coarctation of aorta b) Pulmonary stenosis c) Aortic stenosis d) Tetralogy of Fallot
Tetralogy of Fallot
When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. Which of the following would most likely explain this assessment finding? a) The spleen increases due to increased destruction of red blood cells. b) The liver increases due to cardiac medications. c) The spleen increases due to frequent infection. d) The liver increases in right-sided heart failure.
The liver increases in right-sided heart failure.
The nurse observes the interaction between the mother and her 9-month-old infant. Which observation requires further evaluation?
The mother speaks in baby talk.
A parent is asking for more information about their infant's patent ductus arteriosus (PDA). What would be included in the education? a) Your child may need multiple surgeries to correct this defect. b) This is caused by an opening that usually closes by 1 week of age. c) This type of defect is caused by having a genetic predisposition for it. d) An IV for fluids will be started immediately.
This is caused by an opening that usually closes by 1 week of age.
A parent asks why their infant with a cyanotic heart defect turns blue. What is the best response by the nurse? a) This is considered a medical emergency and needs immediate surgery. b) This is due to a decreased amount of oxygen to the peripheral tissue. c) This is due to the lack of oxygen to the brain. d) This is a sign of heart failure.
This is due to a decreased amount of oxygen to the peripheral tissue.
A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. These goals should be set with the understanding that:
Unknown extent of the disability requires continual adjustments
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) "The feeling of the heart skipping a beat is common." d) "We need to watch for changes in skin color or difficulty breathing."
"The feeling of the heart skipping a beat is common."
The mother of an infant with hypertrophic pyloric stenosis states that she has never heard of this disorder and asks many questions. What should the nurse emphasize when responding?
"This disorder has an excellent prognosis."
A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?
2 hours after feedings
The nurse is conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention? a) Accentuated third heart sound b) Decreased blood pressure c) Heart murmur d) Cool, clammy, pale extremities
Accentuated third heart sound
A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?
By palpating the anterior fontanel
A nurse is reviewing blood work on a patient with a cyanotic heart defect. Which of the following results would most likely be seen in a patient experiencing polycythemia? a) Increased WBC b) Increased RBC c) Decreased RBC d) Decreased WBC
Increased RBC
A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? (Select all that apply.)
Pureed pears Pureed carrots Mashed sweet potatoes
Infants with congenital heart disease should not be allowed to become dehydrated because this makes them prone to a) cerebrovascular accident. b) jaundice. c) tachycardia. d) seizures.
cerebrovascular accident (can develop thrombi if they become dehydrated)
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: a) bounding pulse. b) narrow pulse. c) hepatomegaly. d) femoral pulse weaker than brachial pulse.
femoral pulse weaker than brachial pulse
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?
rectal biopsy
A 2-month-old infant is to have a nasogastric tube inserted. The nurse expects that:
A pacifier will be offered to lessen gagging and allow easier insertion of the tube
The nurse is administering medications to the child with congestive heart failure. Large doses of which of the following medications are used initially in the treatment of CHF to attain a therapeutic level? a) Ferrous sulfate b) Digoxin (Lanoxin) c) Furosemide (Lasix) d) Albuterol sulfate
Digoxin (Lanoxin)
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?
Using modified techniques for feeding
A nurse is caring for an infant who has undergone myringotomy because of recurrent otitis media. What does the nurse expect to note when providing care to this child?
Drainage into the external auditory canal
For how long should a nurse maintain isolation of a child with bacterial meningitis?
For 48 hours after antibiotic therapy begins
A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which of the following should the nurse say to the girl's mother in response to these findings? a) "Your daughter has a functional heart murmur; I recommend that you limit her physical activity so that her heart rate is not elevated for long periods of time." b) "Your daughter has an organic heart murmur, which indicates that she has some degree of heart disease. The doctor will provide a referral to a good cardiologist." c) Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her. d) "Your daughter has an innocent heart murmur, which is nothing to worry about."
"Your daughter has an innocent heart murmur, which is nothing to worry about."
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. The infant's breathing is deep, rapid, and unlabored. The mother states that the infant has had liquid stools and no obvious urine output. What problem does the nurse conclude that the infant is experiencing?
-metabolic acidosis
A child with β-thalassemia is receiving therapy that includes multiple blood transfusions. This child is at increased risk for which complication?
-pulmonary edema
The nurse is caring for a child after a cardiac catheterization. What is the nursing priority? 1. Allow early ambulation to encourage activity participation. 2. Check pulses above the catheter insertion site for strength and quality. 3. Assess extremity distal to the insertion site for temperature and color. 4. Change the dressing to evaluate the site for infection.
Assess extremity distal to the insertion site for temperature and color.
The parents of a 3-month old infant who is breastfed ask the nurse how to prevent nutritional anemia. What is the best response by the nurse?
Baby cereal or an iron supplement should be given around 4 months of age
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) Presacral region b) Lower extremities c) Hands d) Face
Lower extremities
A 3-week-old infant has surgery for esophageal atresia. What is the immediate postoperative nursing care priority for this infant?
Checking the patency of the nasogastric tube
What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
Clubbing of fingers
An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What care should the nurse implement that is specific for this infant's condition?
Elevating the infant's head higher than the hips
A nurse admits an infant with a possible diagnosis of congestive heart failure. Which of the following signs and symptoms would the infant most likely be exhibiting? a) Rapid weight gain b) Yellowish color c) Bradycardia d) Feeding problems
Feeding problems
During change-of-shift report, the oncoming nurse receives information about a 14-month-old infant who underwent cleft palate repair the previous day. The child is currently on a full-liquid diet from cups only. No spoons or straws are allowed in the child's mouth. In addition, the child has elbow restraints on both arms. What care should the nurse include during the course of the shift?
Finishing each meal with a drink of water
A 2-month-old infant is admitted to the pediatric unit for observation after an automobile collision. Family members are unable to stay. How can the nurse best provide psychological comfort for the infant?
Following a routine to which the infant is accustomed
A 2-day-old infant was just diagnosed with aortic stenosis. What is the most likely nursing assessment finding? 1. Gallop and rales. 2. Blood pressure discrepancies in the extremities. 3. Right ventricular hypertrophy on ECG. 4. Heart murmur.
Heart murmur.
An 8-month-old has a ventricular septal defect. Which nursing diagnosis below would best apply? a) Impaired skin integrity related to poor peripheral circulation b) Impaired gas exchange related to a right-to-left shunt c) Ineffective airway clearance related to altered pulmonary status d) Ineffective tissue perfusion related to inefficiency of the heart as a pump
Ineffective tissue perfusion related to inefficiency of the heart as a pump
An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?
Infants' hip joints are cartilaginous, allowing molding of the acetabulum.
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. Which of the following should the nurse mention in explaining how this diagnostic test works? a) High-frequency sound waves are directed toward the heart b) A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy 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
High-frequency sound waves are directed toward the heart
An infant with a myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates the parent-child relationship in the preoperative period? Correct1 Encouraging the parents to stroke their infant
Encouraging the parents to stroke their infant