PrepU ch. 21

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? 150 beats per minute 100 beats per minute 60 beats per minute 80 beats per minute

100 beats per minute

The nurse is caring for an infant girl with a suspected cardiovascular disorder. Which statement by the mother would warrant further investigation? "I don't notice any rapid breathing patterns." "The baby usually drinks all of her bottle." "My baby does not make any grunting noises." "The baby seems more comfortable over my shoulder."

"The baby seems more comfortable over my shoulder."

A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that the physician will most likely order which medication? Indomethacin Alprostadil Spironolactone Heparin

Indomethacin

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

Ineffective tissue perfusion related to inefficiency of the heart as a pump

The nurse is planning care for a 6-month-old infant with a large ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this client? Impaired gas exchange related to a right-to-left shunt Impaired skin integrity related to poor peripheral circulation Ineffective airway clearance related to altered pulmonary status Ineffective tissue perfusion related to left heart dilation from increased pulmonary blood flow

Ineffective tissue perfusion related to left heart dilation from increased pulmonary blood flow

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? Initiate intravenous access. Administer acetaminophen. Assess cervical lymph nodes. Place the child on a soft diet.

Initiate intravenous access.

After teaching a group of students about acute rheumatic fever, the instructor determines that the teaching was successful when the students identify which assessment finding? Jerky movements of the face and upper extremities Black lines Osler nodes Janeway lesions

Jerky movements of the face and upper extremities

The nurse is preparing a teaching plan for the parents of a child who has been diagnosed with a congenital heart defect. What would the nurse be least likely to include? Daily weight assessment Maintenance of strict bed rest Prevention of infection Signs of complications

Maintenance of strict bed rest

A nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin? Nausea and vomiting Fever and tinnitus Ataxia Hypertension

Nausea and vomiting

Which nursing diagnosis would best apply to a child experiencing rheumatic fever? Disturbed sleep pattern related to hyperexcitability Activity intolerance related to increased cardiac workload Risk for self-directed violence related to development of cerebral anoxia Ineffective breathing pattern related to cardiomegaly

Activity intolerance related to increased cardiac workload

A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant? Administer oxygen. Provide large, less frequent feedings. Administer antidiuretic. Restrict fluids.

Administer oxygen.

After assessing a child's blood pressure, the nurse determines the pulse pressure and finds that it is narrowed. What would the nurse identify as associated with this finding? Complete heart block Aortic stenosis Patent ductus arteriosus Aortic insufficiency

Aortic stenosis

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? Contact the physician. Ensure that the child's leg is kept straight. Apply pressure 1 inch above the site. Change the dressing.

Apply pressure 1 inch above the site

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition? Auscultating for a cardiac murmur Recording an upper extremity blood pressure Observing for excessive crying Assessing for the presence of femoral pulses

Assessing for the presence of femoral pulses

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? Apply EMLA cream to the catheter insertion site 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 Record pedal pulses

Avoid drawing a blood specimen from the right femoral vein before the procedure

What information would be included in the care plan of an infant in heart failure? Maintain child in the supine position. Encourage larger, less frequent feedings. Administer digoxin even if the infant is vomiting. Begin formulas with increased calories.

Begin formulas with increased calories.

Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder? Prevent dehydration. Expect the skin to turn yellow. Encourage progressive activity. Prepare for seizures.

Prevent dehydration.

A nurse is assessing a young child and suspects coarctation of the aorta based on which finding? Hypotension Excessive crying Diastolic murmur Unequal upper and lower extremity pulses

Unequal upper and lower extremity pulses

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

altered cardiopulmonary tissue perfusion risk

When assessing an infant born at 32 weeks' gestation, which finding would lead the nurse to suspect that the newborn has a patent ductus arteriosus (PDA)? weak, thready pulse high diastolic arterial pressure continuous murmur on auscultation decreased pulse rate

continuous murmur on auscultation

What evaluation best illustrates the effectiveness of furosemide therapy in a child diagnosed with congestive heart failure (CHF)? The child: has a heart rate within acceptable limits for age. does not become overly tired when awake. has clear breath sounds. has appropriate weight gain for age.

has clear breath sounds.

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? Kawasaki Disease infective endocarditis heart failure cardiomyopathy

heart failure

Which action should the nurse implement for an infant who develops heart failure? placing in a semi-Fowler position restricting daily milk intake keeping in a supine position planning ways to reduce salt intake

placing in a semi-Fowler position

What would be the most important measure to implement for an infant who develops heart failure? placing the infant in a semi-Fowler position restricting milk intake daily keeping the infant supine and playing quiet games planning ways to reduce salt intake

placing the infant in a semi-Fowler position

A nurse is caring for a child who is experiencing heart failure. Which assessment data was most likely seen when initially examined? polyuria bradycardia splenomegaly tachycardia

tachycardia