PEDS PrepU Ch. 41
The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure? A) "He gets sweaty when he eats." B) "He does not seem short of breath." C) "He does not seem sick." D) "He seems to have a normal appetite."
A) "He gets sweaty when he eats." Diaphoresis with nipple feeding indicates heart failure. Shortness of breath would suggest heart failure. Children with heart failure experience subtle signs that suggest that something is wrong. Children with heart failure often display subtle signs such as difficulty feeding.
The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells? A) "He likes to stop and squat wherever he walks." B) "He walks very quickly and never stops moving." C) "He takes one nap a day and is fairly active." D) "He does not seem to have difficulty breathing."
A) "He likes to stop and squat wherever he walks." The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance. Constant movement and quick walking are normal for a toddler. Activity level with a daily nap is typical of a toddler. Difficulty breathing would suggest a problem.
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) "The feeling of the heart skipping a beat is common." B) "We need to avoid a tub bath for the next 3 days." C) "Strenuous activity should be limited for the next 3 days." D) "We need to watch for changes in skin color or difficulty breathing."
A) "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.
The parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best? A) "The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." B) "Increased cardiac workload from your toddler's heart defect affects various parts of the body, including the fingers." C) "The number of red blood cells has significantly increased from the heart defect, resulting in the cells pooling in the fingertips." D) "This is a common complication of tricuspid atresia. Unfortunately, there is nothing we can do to treat it."
A) "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 to the parents what is happening with their child. Clubbing is not the result of increased cardiac workload. Red blood cell pooling is not the cause of clubbing. Although clubbing is a possible result of tricuspid atresia, telling the parents this is a "common complication" does not address the parent's concerns.
A nurse is 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? A) "Your daughter has an innocent heart murmur, which is nothing to worry about." B) "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." C) "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." D) Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her.
A) "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 child admitted to the hospital for a cardiac catheterization. Upon return from the cardiac catheterization, which nursing action is priority? A) Assess the dressing at the insertion site. B) Maintain patency of intravenous access. C) Apply blood pressure monitor. D) Palpate for pulses in bilateral extremities.
A) Assess the dressing at the insertion site. The child returning from a cardiac catheterization is at risk for hemorrhage from the insertion site. The nurse will assess the dressing at the insertion site immediately upon the child's return from the procedure. Palpating pulses, maintaining IV patency, and applying a blood pressure monitor would be done after first assessing the child for bleeding. Although assessing pulses will provide the nurse with information about the circulatory status of the extremities, weak pulse strength is a later sign of hemorrhage than visually assessing the insertion site.
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) Avoid drawing a blood specimen from the right femoral vein before the procedure B) Keep the child NPO for 2 to 4 hours before the procedure C) Record pedal pulses D) Apply EMLA cream to the catheter insertion site
A) 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 will the nurse include in the feeding plan for a breastfed infant with congenital heart disease? A) Breastfeed with small, frequent feeds. B) Ensure output of a minimum 5 wet diapers daily. C) Assess weight gain monthly. D) Feed on schedule every 4 hours to promote rest.
A) 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.
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? A) Child A with a total cholesterol of 150 mg/dl and low-density lipoprotein (LDL) of 80 mg/dl. B) Child B with a total cholesterol level of 175 mg/dl and LDL of 105 mg/dl. C) Child C with a total cholesterol level of 190 mg/dl and LDL of 125 mg/dl. D) Child D with a total cholesterol level of 220 mg/dl and LDL of 138 mg/dl.
A) 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 assessing the heart rate of a 6-month-old infant and determines it to be 82 beats/min. What action should the nurse take first? A) Conduct a focused cardiovascular assessment. B) Reassess the heart rate in 5 minutes. C) Report the finding to the health care provider. D) Obtain a health history from the parent.
A) Conduct a focused cardiovascular assessment. The normal infant heart rate averages 90 to 160 beats/min. This infant's heart rate is low. The nurse should first conduct a focused cardiovascular assessment. After that is completed, the findings can be reported to the health care provider. Obtaining a health history can be beneficial, but with a low heart rate, the nurse would want to know first if there are any other clinical signs indicating a problem or a reason for the heart rate. The heart rate should be reassessed, but not necessarily in a 5-minute window. The heart rate should be assessed via apical pulse for a full 60 seconds.
A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting? A) Feeding problems B) Bradypnea C) Bradycardia D) Yellowish color
A) 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.
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) High-frequency sound waves are directed toward the heart B) X-rays are directed toward the heart C) A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video D) A microphone is placed on the child's chest to record heart sounds and translate them into electrical energy
A) 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.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? A) Peeling hands and feet; fever B) Decreased heart rate and impalpable pulse C) Irritability and dry mucous membranes D) Low blood pressure and decreased heart rate
A) 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.
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) Place the child in a knee-to-chest position. B) Use a calm, comforting approach. C) Provide supplemental oxygen. A) Administer morphine as prescribed.
A) Place the child in a knee-to-chest position. The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed. A calm, comforting approach should be used but is not the priority action.
An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority? A) Place the infant in the knee-chest position. B) Start an IV for fluids. C) Prepare the infant for surgery. D) Raise the head of the bed.
A) Place the infant in the knee-chest position. Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.
A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta? A) Pulses weaker in lower extremities compared to upper extremities B) Pulses weaker in upper extremities compared to lower extremities C) Cyanosis with crying D) Cyanosis with feeding
A) 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 systemic 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.
When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure? A) Tachycardia B) Bradycardia C) Inability to sweat D) Splenomegaly
A) Tachycardia Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.
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 measuring the fluid level in the heart. C) The wires are left in the heart for 1 month after surgery in case of potential arrhythmias. 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.
Parents are told that 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 parents? A) This type of shunting causes an increase of blood to the lungs. B) This type of shunting causes an increase of blood to the systemic circulation. C) This type of shunting causes a decrease of blood to the lungs. D) This type of shunting causes a decrease of blood to the brain.
A) 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 admits a 5-year-old child to the pediatric unit with a history of fever for 1 week (above). The child has been unresponsive to antibiotics for suspected strep throat. What medication(s) does the nurse anticipate in the child's plan of care? Select all that apply. A) acetaminophen B) aspirin C) intravenous immunoglobulin (IVIG) D) metoprolol E) warfarin
A) acetaminophen B) aspirin C) intravenous immunoglobulin (IVIG) This child is presenting with symptoms of Kawasaki disease, which include high fever unresponsive to antibiotics; dry, cracked lips and tongue; diffuse polymorphic rash; peripheral edema; and desquamation on the hands and feet. Pharmacologic treatment of the acute phase of Kawasaki disease includes aspirin and IVIG to reduce inflammation in the coronary arteries and prevent coronary thrombosis. It also includes acetaminophen for fever management. Metoprolol and warfarin are not used in the treatment of Kawasaki disease.
A group of students are reviewing information about acute rheumatic fever. The students demonstrate a need for additional review when they identify what as a major Jones criterion? A) arthralgia B) carditis C) erythema marginatum D) subcutaneous nodules
A) arthralgia Arthralgia is considered a minor criterion. Carditis is a major criterion. Erythema marginatum is considered a major criterion. Subcutaneous nodules are considered a major criterion.
The nurse is assessing a child with aortic stenosis. Which findings would the nurse most likely assess? Select all that apply. A) chest pain with activity B) dizziness with prolonged standing C) thrill palpated at base of heart D) moderately loud systolic murmur at the base of the heart E) blood pressure in arms significantly higher than in legs
A) chest pain with activity B) dizziness with prolonged standing C) thrill palpated at base of heart Assessment findings associated with aortic stenosis include angina or chest pain with activity, dizziness with prolonged standing, and a thrill palpated at the base of the heart. A moderately loud systolic murmur at the base of the heart suggests coarctation of the aorta. Blood pressure that is significantly higher in the arms than in the legs, possibly 20 mm Hg or higher, also suggests coarctation of the aorta.
After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: A) femoral pulse weaker than brachial pulse. B) bounding pulse. C) narrow pulse. D) hepatomegaly.
A) 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 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? A) heart failure B) infective endocarditis C) cardiomyopathy D) Kawasaki Disease
A) 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, and irritability are signs of Kawasaki disease.
A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Where should the nurse expect to note edema in this child? A) lower extremities B) face C) presacral region D) hands
A) 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 is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers? A) nonsterioidal anti-inflammatory drugs (NSAIDs) B) antiviral C) insulin D) phenytoin
A) nonsterioidal anti-inflammatory drugs (NSAIDs) Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids. Insulin would be given for diabetes and phenytoin for seizure disorders. Antivirals are not relevant to the treatment of a bacterial infection.
A child has been admitted to the inpatient unit to rule out acute Kawasaki disease. A series of laboratory tests have been ordered. Which findings are consistent with this disease? Select all that apply. A) reduced hemoglobin levels B) reduced white blood cell count C) elevated erythrocyte sedimentation rate (ESR) D) negative C-reactive protein levels E) reduced platelet levels
A) reduced hemoglobin levels C) elevated erythrocyte sedimentation rate (ESR) Kawasaki disease is an acute systemic vasculitis occurring mostly in children 6 months to 5 years of age. It is the leading cause of acquired heart disease among children. The CBC count may reveal mild to moderate anemia, an elevated white blood cell count during the acute phase, and significant thrombocytosis (elevated platelet count [500,000 to 1 million]) in the later phase. The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are elevated.
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 (6.9 kg). Calculate the infant's morphine sulfate dose. Record your answer using one decimal place.
Answer: 0.7 The does should be calculated weight in kilograms. The infant weighs 6.9 kg. For each kilogram of body weight, the infant should receive 0.1 mg of morphine sulfate. 6.9 kg x 0.1 mg/1 kg = 0.69 mg. Rounded to the tenth place = 0.7 mg. The infant will receive 0.7 mg of morphine sulfate.
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? A) "This disorder is caused by genetic factors." B) "Children who have this diagnosis may have had strep throat." C) "Being up-to-date on immunizations is the best way to prevent this disorder." D) "The onset and progression of this disorder is rapid."
B) "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 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) "Our child will be so excited to get back to soccer league in a few days." B) "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." C) "It's wonderful that our child will never have an abnormal heart rhythm again." D) "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." E) "We know how important our child's medications are so we will write out a schedule to be sure medications are taken as prescribed."
B) "We will be sure to not allow our child to ride a bicycle for at least 2 weeks." D) "We will be sure to monitor our child for any signs of infection and notify the doctor if we notice any." E) "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.
Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition? A) Observing for excessive crying B) Assessing for the presence of femoral pulses C) Recording an upper extremity blood pressure D) Auscultating for a cardiac murmur
B) 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 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.
What information would be included in the care plan of an infant in heart failure? A) Encourage larger, less frequent feedings. B) Begin formulas with increased calories. C) Maintain child in the supine position. D) Administer digoxin even if the infant is vomiting.
B) 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.
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) Ineffective tissue perfusion related to inefficiency of the heart as a pump C) Impaired gas exchange related to a right-to-left shunt D) Impaired skin integrity related to poor peripheral circulation
B) 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.
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 intravenous access. C) Administer acetaminophen. D) Assess cervical lymph nodes.
B) 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.
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) Notify the doctor immediately. C) Administer epinephrine. D) Observe vitals every two hours.
B) 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.
When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? A) Leukopenia B) Polycythemia C) Increased platelet level D) Anemia
B) 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.
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 probably need surgery. B) The child will need the blood pressure checked two more times. C) Advise the child go to the emergency room. D) This is a normal result for a child this age.
B) The child will need the blood pressure 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 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 right groin is soft without edema. B) The child's right foot is cool with a pulse assessed only with the use of a Doppler. C) The child has a temperature of 102.4° F (39.1° C). D) The child is reporting nausea. E) The child has a runny nose.
B) The child's right foot is cool with a pulse assessed only with the use of a Doppler. C) The child has a temperature of 102.4° F (39.1° C). D) The child is reporting nausea. 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 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) bounding pulse C) preference to resting on the right side D) pitting periorbital edema
B) bounding pulse A bounding pulse is characteristic of patent ductus arteriosus 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 caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding? A) steady weight gain since birth B) softening of the nail beds C) appropriate mastery of developmental milestones D) intact rooting reflex
B) softening of the nail beds Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends.
A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis? A) coarctation of aorta B) tetralogy of Fallot C) pulmonary stenosis D) aortic stenosis
B) 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 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? A) "Are you sure you are making nutrient-dense foods?" B) "Maybe your child doesn't really like the foods your making. This could lead to not gaining sufficient weight." C) "It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." D) "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."
C) "It's great you are providing nutritious meals, but small, 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 the parents as to whether they are making nutritious foods or foods preferred by the child does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.
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? A) The liver size increases due to cardiac medications. B) The spleen size increases due to frequent infection. C) The liver size increases in right-sided heart failure. D) The spleen size increases due to increased destruction of red blood cells.
C) 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.
A mother is asking for more information about her 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) An IV for fluids will be started immediately. C) This is caused by an opening that usually closes by 1 week of age. D) This type of defect is caused by having a genetic predisposition for it.
C) This is caused by an opening that usually closes by 1 week of age. A PDA is caused by an opening called the ductus arteriosus. A PDA usually closes by 1 week of age. If it does not close, the defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.
Which finding(s) is a major criterion used to help the health care provider diagnose acute rheumatic fever in a child? Select all that apply. A) elevated erythrocyte sedimentation rate B) temperature of 101.2°F (38.4°C) C) painless nodules located on the wrists D) pericarditis with the presence of a new heart murmur E) heart block with a prolonged PR interval
C) painless nodules located on the wrists D) pericarditis with the presence of a new heart murmur Subcutaneous nodules and carditis are considered major criteria used in the diagnosing of acute rheumatic fever. The other options are minor criteria.
What would be the most important measure to implement for an infant who develops heart failure? A) restricting milk intake daily B) planning ways to reduce salt intake C) placing the infant in a semi-Fowler position D) keeping the infant supine and playing quiet games
C) placing the infant in a semi-Fowler position Placing an infant with heart failure in a semi-Fowler 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 lungs. Infants with heart disease need calories to grow. They are given formula or breast milk which is fortified with extra nutrients. Thus the infant can have an intake of the same amount of fluid but receive extra nutrients.
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) "I can only place oxygen on your child if the doctor orders oxygen." B) "Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." C) "This is something we should talk with the physician about. Maybe it would help your baby." D) "While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help."
D) "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 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? A) 80 to 90/40 to 64 mm Hg B) 80 to 100/64 to 80 mm Hg C) 94 to 112/56 to 60 mm Hg D) 100 to 120/70 to 80 mm Hg
D) 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 preschool-age child's blood pressure averages 90 to 110/55 to 75 mm Hg. The normal school-age child's blood pressure averages 100 to 120/60 to 75 mm Hg.
A nurse is preparing to administer a prescribed dose of digoxin to an 6-month-old infant. After assessing the infant's apical pulse, the nurse decides to withhold the dose and notify the health care provider. The nurse bases this decision on which apical pulse rate? A) 118 beats/min B) 102 beats/min C) 94 beats/min D) 80 beats/min
D) 80 beats/min Prior to administering each dose of digoxin, the nurse would count the apical pulse for 1 full minute, noting rate, rhythm, and quality. The nurse would withhold the dose and notify the health care provider if the apical pulse is less than 60 in an adolescent, less than 90 in an infant.
The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first? A) Contact the health care provider. B) Apply appropriate oxygen device. C) Prepare for balloon angioplasty. D) Assess blood pressure in all extremities.
D) 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 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 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 RBC C) Decreased WBC D) Increased RBC
D) 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 conducting a physical examination of an infant with a suspected cardiovascular disorder. Which assessment finding is suggestive of sudden ventricular distention? A) decreased blood pressure B) heart murmur C) cool, clammy, pale extremities D) accentuated third heart sound
D) accentuated third heart sound An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure; cool, clammy, and pale extremities; and a heart murmur are all associated with cardiovascular disorders. However, these findings do not specifically indicate sudden ventricular distention.
Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? A) surgical site infection risk B) acute parental anxiety C) fluid overload 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.
Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? A) surgical site infection risk B) acute parental anxiety C) fluid overload 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.