Peds: PrepU Ch. 19
The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant's body weight. The infant weighs 15.2 lb (6.81 kg). Calculate the infant's morphine sulfate dose. Record your answer using one decimal place.
0.7
The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding? -80/40 mm Hg -100/60 mm Hg -90/64 mm Hg -110/60 mm Hg
100/60 mm Hg The toddler's or preschooler's blood pressure averages 80 to 100/64 mm Hg. The normal infant's blood pressure is about 80/40 mm Hg. The school-age child's blood pressure averages 94 to 112/56 mm Hg. An adolescent's blood pressure averages 100 to 120/50 to 70 mm Hg.
The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond? -"Are you sure you are making nutrient dense foods?" -"It's great you are providing nutritious meals, but smaller frequent meals will tire your child less and promote weight gain." -"It's hard to get your child to eat enough at this age to maintain their weight since they are expending so much energy with the heart condition." -"Maybe your child doesn't really like the foods your making. This could lead to not gaining sufficient weight."
"It's great you are providing nutritious meals, but smaller frequent meals will tire your child less and promote weight gain." Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child. Questioning if the parents are making nutritious foods or foods the child likes does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.
A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings? -"Your daughter has an innocent heart murmur, which is nothing to worry about." -Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her. -"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." -"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."
"Your daughter has an innocent heart murmur, which is nothing to worry about." The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.
The nurse is caring for a 7-year-old who is being discharged following surgery with a Gore® Helex device to repair an atrial septal defect. The parents of the child demonstrate understanding of the procedure with which statements? Select all that apply. -"Our child will be so excited to get back to soccer league in a few days." -"We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." -"We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." -"It's wonderful that our child will never have an abnormal heart rhythm again." -"We will be sure to not allow our child to ride a bicycle for at least 2 weeks."
-"We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." -We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed." -"We will be sure to not allow our child to ride a bicycle for at least 2 weeks." 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 pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply. -2-year-old child whose digoxin level was 2.4 ng/mL from a blood draw this morning -16-year-old child with a heart rate of 54 beats per minute -12-year-old child whose digoxin level was 0.9 ng/ mL on a blood draw this morning -4-month-old child with an apical heart rate of 102 beats per minute -5-year-old child who developed vomiting and diarrhea, and is difficult to arouse
-2-year-old child whose digoxin level was 2.4 ng/mL from a blood draw this morning -16-year-old child with a heart rate of 54 beats per minute -5-year-old child who developed vomiting and diarrhea, and is difficult to arouse The nurse should not administer digoxin to children with the following issues: The adolescent with an apical pulse under 60 beats per minute, the child with a digoxin level above 2 ng/mL, and the child who exhibiting signs of digoxin toxicity.
An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply? -Ineffective airway clearance related to altered pulmonary status -Impaired skin integrity related to poor peripheral circulation -Impaired gas exchange related to a right-to-left shunt -Ineffective tissue perfusion related to inefficiency of the heart as a pump
-Ineffective tissue perfusion related to inefficiency of the heart as a pump A ventriculoseptal 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.
A nurse is developing the plan of care for a 7-year-old child diagnosed with congenital heart disease and a history of hypercyanotic spells. Which interventions would the nurse include in the child's plan of care to address these spells? Select all that apply. -Providing supplemental oxygen -Giving parenteral morphine sulfate -Encouraging increased activity -Administering oral fluids as prescribed -Placing the child in the orthopneic position
-Providing supplemental oxygen -Giving parenteral morphine sulfate For a child experiencing a hypercyanotic spell, the nurse should use a calm, comforting approach and place the child in a knee-to-chest position, provide supplemental oxygen, administer morphine sulfate (0.1 mg/kg IV, IM, or SQ), supply IV fluids and administer propranolol (0.1 mg/kg IV).
A child has been prescribed spironolactone. Which laboratory values should be reviewed when following up on this medication? Select all that apply. -Serum chloride levels -Serum calcium levels -Serum potassium levels -Serum magnesium levels -Serum sodium levels
-Serum potassium levels -Serum sodium levels Spironolactone is a potassium sparing diuretic that competes with aldosterone to result in increased water and sodium excretion (spares potassium). Used to manage edema due to heart failure and for treatment of hypertension. Serum potassium and sodium levels should be evaluated in someone taking this medication.
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? -The child has a runny nose. -The child is reporting nausea. -The child's right foot is cool with a pulse assessed only with the use of a Doppler. -The right groin is soft without edema. -The child has a temperature of 102.4° F (39.1° C).
-The child is reporting nausea. -The child's right foot is cool with a pulse assessed only with the use of a Doppler. -The child has a temperature of 102.4° F (39.1° C). The 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.
The nurse takes 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? -80 beats per minute -150 beats per minute -100 beats per minute -60 beats per minute
100 beats per minute Digoxin is a cardiac glycoside that works by increasing the contractility of the heart muscle. It decreases conduction and increases the force of the heart beat. The result is a slowing of the heart rate. An 8-month-old infant has a normal range of heart rate of 80 to 150 beats per minute while awake and resting and 80 to 130 beats per minute while sleeping. The accepted practice for this age child is to hold the digoxin if the the heart rate is 90 beats per minute or less. It would be safe to administer the drug if the heart rate is 100 beats per minute. If the child has a heart rate of 150 beats per minute, further assessment should be made prior to administering the drug.
The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy? -94 to 112/56 to 60 mm Hg -80 to 100/64 to 80 mm Hg -100 to 120/70 to 80 mm Hg -80 to 90/40 to 64 mm Hg
100 to 120/70 to 80 mm Hg The normal adolescent's blood pressure averages 100 to 120/70 to 80 mm Hg. The average infant's blood pressure is about 80/55 mm Hg. The toddler or preschooler's blood pressure averages 90 to 110/55 to 75 mm Hg. The normal school-ager's blood pressure averages 100 to 120/60 to 75 mm Hg.
The nurse is assessing the heart rate of a healthy 6-month-old. In which range should the nurse expect the infant's heart rate? -60 to 68 bpm -90 to 160 bpm -80 to 105 bpm -70 to 80 bpm
90 to 160 bpm The normal infant heart rate averages 90 to 160 beats per minute (bpm); the toddler's or preschooler's is 80 to 115, the school-age child's is 60 to 100 bpm.
Which nursing diagnosis would best apply to a child with rheumatic fever? -Disturbed sleep pattern related to hyperexcitability -Ineffective breathing pattern related to cardiomegaly -Risk for self-directed violence related to development of cerebral anoxia -Activity intolerance related to inability of heart to sustain extra workload
Activity intolerance related to inability of heart to sustain extra workload Acute rheumatic fever affects the joints, central nervous system, skin and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfer with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.
A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant? -Provide large, less frequent feedings. -Restrict fluids. -Administer oxygen. -Administer antidiuretic.
Administer oxygen. If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.
The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate? -Change the dressing. -Apply pressure 1 inch above the site. -Ensure that the child's leg is kept straight. -Contact the physician.
Apply pressure 1 inch above the site. If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.
The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first? -Apply appropriate oxygen device. -Assess blood pressure in all extremities. -Prepare for balloon angioplasty. -Contact the health care provider.
Assess blood pressure 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 gather 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.
Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition? -Recording an upper extremity blood pressure -Assessing for the presence of femoral pulses -Auscultating for a cardiac murmur -Observing for excessive crying
Assessing for the presence of femoral pulses Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing blood flow is impeded causing to pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses.There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.
A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection? -Keep the child NPO for 2 to 4 hours before the procedure -Avoid drawing a blood specimen from the right femoral vein before the procedure -Apply EMLA cream to the catheter insertion site -Record pedal pulses
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.
What information would be included in the care plan of an infant in heart failure? -Encourage larger, less frequent feedings. -Maintain child in the supine position. -Begin formulas with increased calories. -Administer digoxin even if the infant is vomiting.
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 times 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 nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note? -Pitting periorbital edema -Appropriate mastery of developmental milestones -Bounding pulse -Preference to resting on the right side
Bounding pulse A bounding pulse is characteristic of patent ductus arteriosis or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.
The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia? -Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL. -Child D with a total cholesterol level of 220 mg/dL and LDL of 138 mg/dL. -Child C with a total cholesterol level of 190 mg/dL and LDL of 125 mg/dL. -Child B with a total cholesterol level of 175 mg/dL and LDL of 105 mg/dL.
Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL. Total cholesterol levels below 170 mg/dL and LDL levels less than 100 mg/dL are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dL and LDL levels greater than or equal to 130 mg/dL are considered elevated and place this child at greatest risk.
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever? -"The onset and progression of this disorder is rapid." -"This disorder is caused by genetic factors." -"Children who have this diagnosis may have had strep throat." -"Being up-to-date on immunizations is the best way to prevent this disorder."
Children who have this diagnosis may have had strep throat Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? -Furosemide -Indomethacin -Digoxin -Alprostadil
Digoxin Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force. Alprostadil is indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects. Furosemide is used for the management of edema associated with heart failure. Indomethacin is used to close a patent ductus arteriosus.
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? -Spironolactone -Digoxin -Ferrous sulfate -Albuterol sulfate
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.
A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting? -Bradypnea -Yellowish color -Feeding problems -Bradycardia
Feeding problems The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.
A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent? -Have the child drink fluids that contain electrolytes. -Have the child be seen by the primary care provider. -Have the child go to the emergency room. -Give acetaminophen for the fever and pain, and have the child rest.
Have the child be seen by the primary care provider Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.
The nurse in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder? -Heart failure -Kawasaki Disease -Cardiomyopathy -Infective endocarditis
Heart failure Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, irritability are signs of Kawasaki disease.
The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child's mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. What should the nurse mention in explaining how this diagnostic test works? -High-frequency sound waves are directed toward the heart -A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video -X-rays are directed toward the heart -A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy
High-frequency sound waves are directed toward the heart Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. For this, high-frequency sound waves, directed toward the heart, are 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 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.
A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia? -Increased RBC -Increased WBC -Decreased RBC -Decreased WBC
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 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? -Administer acetaminophen. -Initiate intravenous access. -Assess cervical lymph nodes. -Place the child on a soft diet.
Initiate intravenous 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.
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse? -It will determine if the heart is enlarged. -This image will clarify the structures within the heart. -It will show if blood is being shunted. -It will determine disturbances in heart conduction.
It will determine if the heart is enlarged. Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.
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? -Face -Presacral region -Lower extremities -Hands
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 child will be undergoing a Holter monitor test. Which statement by the mother indicates the need for further instruction? -"We do not need to alter our activities during the testing period." -"Wearing a snug shirt the day of the test will be helpful." -"This test will monitor my child for about 24 hours." -"My child cannot have any thing to eat or drink after midnight the day of the test."
My child cannot have any thing to eat or drink after midnight the day of the test." Ambulatory electrocardiographic monitoring (Holter) testing is an exam that spans approximately 24 hours. The test is done to review the activity of the heart. The individual is encouraged to follow their normal activities during the test. There is no need for the child to be NPO prior to or during the test.
A nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin? -Ataxia -Nausea and vomiting -Fever and tinnitus -Hypertension
Nausea and vomiting Digoxin is a cardiac glycoside and antirrhythmic. It can cause toxicity if the dosages increase due to poor absorption, dehydration, etc. Signs of digoxin toxcity are nausea and vomiting, lethargy, and bradycardia. The apical pulse should be taken for one full minute prior to administering digoxin. The dosage should be held if the pulse rate is less than 60 beats/min in an adolescent or less than 90 beats/min in an infant. The other symptoms listed do not relate to digoxin toxicity and could occur for numerous reasons.
A nurse suspects a child is experiencing cardiac tamponade after heart surgery. What would be the priority nursing intervention? -Notify the doctor immediately. -Administer epinephrine. -Observe vitals every two hours. -Elevate the head of the bed.
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 client's newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the client, which defect would the nurse's description include? -Left ventricular hypertrophy -Overriding of the aorta -Atrial septal defect -Stenosis of the aorta
Overriding of the aorta One of the components in the tetralogy of Fallot is overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with 4 components. The defects in the tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta and left ventricular hypertrophy are not components of tetralogy of Fallot.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? -Low blood pressure and decreased heart rate -Decreased heart rate and impalpable pulse -Irritability and dry mucous membranes -Peeling hands and feet and fever
Peeling hands and feet and fever Kawasaki disease is an acute sytemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region.The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease.The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.
A 1-year-old with tetralogy of Fallot turns blue during a temper tantrum. What will the nurse do first? -Explain to the child the need to calm down -Place child in the knee-to-chest position -Assess for an irregular heart rate -Listen for an increased respiratory rate
Place child in the knee-to-chest position Tetrology of Fallot is a cyanotic heart defect. Hypercyanosis can develop suddenly. The symptoms are increased cyanosis, hypoxemia, dyspnea and agitation. The nurse should use a calm, comforting approach with the child and place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. This position increases pulmonary blood flow by increasing systemic vascular resistance. The additional interventions for a hypercyanotic spell are to administer oxygen, and give morphine, IV fluids, and propanalol. A child will not understand to calm down and cannot be expected to listen during a temper tantrum. Assessing the child's heart rate and respirations are not priority. Perfusion is priority for this client at this time.
A nurse is giving discharge instructions to the parents of a newborn with a congenital heart disorder. What should the nurse instruct the parents to do in the event that the child becomes cyanotic? -Administer prescribed amoxicillin -Perform hands-on CPR -Administer low-dose aspirin -Place him in a knee-chest position
Place him in a knee-chest position Before parents leave the hospital with a newborn who has a congenital heart disorder, be certain they have the name and number of the health professional to call if they have a question about their infant's health. Review with them the steps to take if their child should become cyanotic, such as placing the child in a knee-chest position. "Hands on" CPR is not recommended for children as it is for adults. Remind parents that children with many types of congenital heart disorders or rheumatic fever need prophylactic low-dose aspirin therapy to avoid blood clotting; although becoming a controversial practice, they may be prescribed antibiotic therapy such as oral amoxicillin before oral surgery.
During assessment of an infant diagnosed with tetralogy of Fallot, the nurse notes bluish colored lips and irritability. Which nursing action is priority? -Place in knee-chest position. -Provide a pacifier to the infant. -Assess oxygen saturation. -Prepare the infant for surgery.
Place in knee-chest position When an infant with tetralogy of Fallot exhibits signs of a hypercyanotic (tet) spell, the nurse's first action should be to place the child in a knee-chest position to increase systemic vascular resistance to force blood through the constricted pulmonic valve and increase oxygenation. Assessing oxygen status is minimally helpful as the nurse has enough assessment data to indicate cyanosis. Providing a pacifier may calm the child, but will not increase systemic vascular resistance, and can be provided after placing the child in knee-chest postion. Preparing the infant for surgery can be done at a later time.
What would be the most important measure to implement for an infant who develops heart failure? -Planning ways to reduce salt intake -Placing the infant in a semi-Fowler's position -Restricting milk intake daily -Keeping the infant supine and playing quiet games
Placing the infant in a semi-Fowler's position Placing an infant with heart failure in a semi-Fowler's position reduces the pressure of the abdominal contents against the chest and allows for better lung expansion. Keeping the infant supine would cause more pressure on the heart and lungs and increase the work of the heart and breathing. Infants with heart disease need calories to grow. They are given formula or breast milk which is fortified with extra nutirents. Thus the infant can have an intake of the same amount of fluid but receive extra nutrients.
When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? -Anemia -Leukopenia -Polycythemia -Increased platelet level
Polycythemia Tetrology of Fallot is a congential heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoiten to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycethemia. 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 Tetrology of Fallot.
A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta? -Pulses weaker in upper extremities compared to lower extremities -Cyanosis with crying -Cyanosis with feeding -Pulses weaker in lower extremities compared to upper extremities
Pulses weaker in lower extremities compared to upper extremities With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased sytemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses. Coarctation is not a cyanotic defect. The cyanosis would be associated with tetralogy of Fallot.
Which nursing diagnosis will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? -Parental anxiety related to lack of knowledge -Risk for ineffective cardiopulmonary tissue perfusion -Risk for infection related to surgical incision -Risk for excess fluid volume related to fluid shifts
Risk for ineffective cardiopulmonary tissue perfusion Nursing priority following cardiac surgery will focus on assessing for ineffective cardiopulmonary tissue perfusion. Monitoring for excess fluid volume, infection, and anxiety will be monitored after ensuring cardiopulmonary tissue perfusion is adequate.
A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor? -Serum potassium level -Serum sodium level -Erythrocyte sedimentation rate -Oxygen saturation level
Serum potassium level Children receiving diuretics should have serum potassium levels obtained because diuretics tend to deplete the body of potassium. This is even more important if the child is also receiving digoxin because low serum potassium levels potentiate or increase the effect of the drug. Serum sodium levels may be obtained in children with heart failure to ensure that an increased sodium level is not causing edema. The erythrocyte sedimentation rate identifies inflammation and is unrelated to the use of diuretics and digoxin. Oxygen saturation levels may be done to evaluate for hypoxemia, but these results would be unrelated to the use of digoxin and diuretics.
The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority? -Administer penicillin. -Assess skin for a rash. -Evaluate C-reactive protein. -Swab throat for culture.
Swab throat for culture. A child with generalized joint pain, pharyngitis, and murmur is exhibiting signs of rheumatic fever. A priority action is to obtain a throat culture to verify presence of a group-A beta-hemolytic streptococcal infection and then administer penicillin. Assessing for a rash is minimally helpful as there is enough assessment data to obtain a throat culture. A high C-reactive protein is an indicator of an active infection, but it will not identify the source of the infection and needed pharmacologic therapy.
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? -Pulmonary stenosis -Coarctation of aorta -Aortic stenosis -Tetralogy of Fallot
Tetralogy of Fallot Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.
The nurse 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? -"We need to avoid a tub bath for the next 3 days." -"The feeling of the heart skipping a beat is common." -"We need to watch for changes in skin color or difficulty breathing." -"Strenuous activity should be limited for the next 3 days."
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.
When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. What would most likely explain this assessment finding? -The spleen size increases due to increased destruction of red blood cells. -The liver size increases in right-sided heart failure. -The liver size increases due to cardiac medications. -The spleen size increases due to frequent infection.
The liver size increases in right-sided heart failure The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.
The parents of a 2-year-old newly diagnosed with tricuspid atresia ask the nurse, "I don't understand why our child's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is most likely to be understood by the parents? -"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." -"Chronic hypoxia from your child's heart defect causes effects in various parts of the body, including the fingers." -"The number of red blood cells has significantly increased from the heart defect, resulting in the cells pooling in the fingertips." -"This is a common complication of tricuspid atresia. Unfortunately there is nothing we can do to treat it."
The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." Clubbing (which is what the parents are describing) of fingertips or toes can occur from the chronic hypoxia that occurs with disorders with decreased pulmonary blood flow, such as tricuspid atresia. Using the term "low oxygen levels in the blood" rather than "chronic hypoxia" is a better way to explain what is happening to the parents. Red blood cell pooling is not the cause of clubbing. Although clubbing is a possible result of tricuspid atresia, telling the parents this is a "common complication" does not address the parent's concerns.
A nurse is interviewing a mother who is about to give birth. Which response would alert the nurse for a higher potential for a heart defect in the newborn? -The mother states she slept all the time while pregnant. -The mother states she has lupus. -The mother has seizures, but did not take medication while pregnant. -The mother states she took acetaminophen while pregnant.
The mother states she has lupus. A health history should be obtained from the pregnant woman. This history should include having problems during birth of any previous children, frequent infections, chromosomal abnormalities, having a premature birth, having an autoimmune disease or taking long-term medications such as corticosteroids. Having lupus while pregnant could contribute to a congenital heart defect. Acetaminophen and sleeping do not affect the newborn's potential for developing a heart defect. The seizure medication can have an impact on the newborn having a heart defect, but not necessarily a history of seizures in the mother. A seizure in the mother would be more related to hypoxia in the newborn than a heart defect.
A mother asks if the reason the infant has a congenital heart defect because of something she did while pregnant. What is the best response by the nurse? -The studies show it is impossible to know what causes heart defects. -No, heart defects are mainly caused by genetic factors. -Yes, there is a chance you caused this defect. -There are several reasons an infant can have a heart defect, let's talk about those causes
There are several reasons an infant can have a heart defect, let's talk about those causes Parents who have a newborn that has a defect are always concerned they did something wrong to cause the defect. They carry a large amount of guilt. The nurse should focus on the therapeutic communication in this situation, while still obtaining more information. The should should never blame the parent because not only is it not therapeutic, but there are many reasons why congenital heart defects occur. The reason for the infant's heart defect may not be known. Using therapeutic communication will reduce the parent's anxiety and guilt. Congenital heart defects can be caused by genetic defects such as chromosomal anomalies but this is not always the case.
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? -The wires are measuring the fluid level in the heart. -The wires will administer ongoing electrical shocks to the heart to maintain rhythm. -These wires are connected to the heart and will detect if your infant's heart gets out of rhythm. -The wires are left in the heart for 1 month after surgery in case needed for potential arrhythmias.
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 preventative 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 not set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization.
A parent is asking for more information about their infant's patent ductus arteriosus (PDA). What would be included in the education? -An IV for fluids will be started immediately. -Your child may need multiple surgeries to correct this defect. -This type of defect is caused by having a genetic predisposition for it. -This is caused by an opening that usually closes by 1 week of age.
This is caused by an opening that usually closes by 1 week of age. A PDA is caused by an opening that usually closes by 1 week of age called the ductus arteriosus. The defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.
A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent? -This invasive test will measure the blockage in the heart. -This test will only determine the size of the heart. -This test that check how blood is flowing through the heart. -This noninvassive test will check the electrical impulses in the heart.
This test that check how blood is flowing through the heart. An echocardiogram (echo) is a noninvassive ultrasound used to assess the heart wall thickness, the size of the heart chambers, the motion of the valves and septa, and the relationship of the great vessels to other cardiac structures. The test evaluates how blood is flowing through the heart and how effective the heart is in pumping. An echo does not check the electrical impulses. This would be done with an electrocardiogram.
A parent is told their infant has a heart defect with a left to right shunt. What is the best way for the nurse to explain this type of shunting to the parent? -This type of shunting causes a decrease of blood to the brain. -This type of shunting causes an increase of blood to the lungs. -This type of shunting causes a decrease of blood to the lungs. -This type of shunting causes an increase of blood to the systemic circulation.
This type of shunting causes an increase of blood to the lungs. This type of shunting causes an increase of blood to the lungs. A right to left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.
The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason? -To build the blood levels to a therapeutic level -To decrease the pain to a tolerable level -To establish a maintenance dose of the drug -To increase the heart rate
To build the blood levels to a therapeutic level The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.
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? -"If she needs dental surgery, we might need additional medication." -"To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years." -"We can stop the penicillin when her symptoms disappear." -"She needs to take the drug for the full 14 days."
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 has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction? -Nausea with diarrhea -Abdominal distress -Wheezing -Stomach upset
Wheezing The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset is common with oral antibiotics and is not something that needs to be reported immediately. Nausea with diarrhea is common with oral antibiotics and does not need to be reported immediately. Abdominal distress is common with oral antibiotics and does 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 ask 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 the nurse? -"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." -"Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." -"I can only place oxygen on your child if the doctor orders oxygen." -"This is something we should talk with the physician about. Maybe it would help your baby."
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 caring for a 3-month-old infant with history of congenital heart disease. The infant is brought to the emergency department with nausea and vomiting for 3 days. Admission laboratory results confirm dehydration. The nurse realizes that the dehydrated infant is at risk for: -jaundice. -a cerebrovascular accident. -tachycardia. -seizure activity.
a cerebrovascular accident. Children who have defects which cause a decreased pulmonary blood flow have decreased oxygen saturation. To compensate the kidneys produce erythropoiten to stimulate the bone marrow to make more red blood cells. The increased red blood cells makes the blood more viscous. If an infant with heart disease becomes dehydrated the infant can develop thrombi from the increased amounts of red blood cells and the viscosity of the blood. This places the infant at risk for a cerebrovascular event. Jaundice would only occur if the liver was involved. Tachycardia and seizures can occur with dehydration but an infant with a congenital heart defect would be at a higher risk for a cerebrovascular event.
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: -narrow pulse. -bounding pulse. -hepatomegaly. -femoral pulse weaker than brachial pulse.
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.