The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?
1. Pallor
2. Cough
3.Tachycardia
4.Slow and shallow breathing
3. Tachycardia
Rationale:
HF is the inability of the heart to pump a sufficient amount of
blood to meet the oxygen and metabolic needs of the body. The early
signs of HF include tachycardia, tachypnea, profuse scalp sweating,
fatigue and irritability, sudden weight gain, and respiratory
distress. A cough may occur in HF as a result of mucosal swelling and
irritation, but is not an early sign. Pallor may be noted in an infant
with HF, but is not an early sign.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Strategic Words
Priority Concepts: Clinical Judgment, Perfusion
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?
1.Immunoglobulin
2.Red blood cell count
3.White blood cell count
4.Anti–streptolysin O titer
4. Rationale :
Rheumatic fever is an inflammatory autoimmune disease that affects
the connective tissues of the heart, joints, skin (subcutaneous
tissues), blood vessels, and central nervous system. A diagnosis of
rheumatic fever is confirmed by the presence of 2 major manifestations
or 1 major and 2 minor manifestations from the Jones criteria. In
addition, evidence of recent streptococcal infection is confirmed by a
positive anti–streptolysin O titer, Streptozyme assay, or anti-DNase B
assay. Options 1, 2, and 3 would not help to confirm the diagnosis of
rheumatic fever.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Analysis
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Inflammation
On the assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
1.Cracked lips
2.Normal appearance
3.Conjunctival hyperemia
4.Desquamation of the skin
3. Rationale:
Kawasaki disease, also known as mucocutaneous lymph node
syndrome, is an acute systemic inflammatory illness. In the acute
stage, the child has a fever, conjunctival hyperemia, red throat,
swollen hands, rash, and enlargement of the cervical lymph nodes. In
the subacute stage, cracking lips and fissures, desquamation of the
skin on the tips of the fingers and toes, joint pain, cardiac
manifestations, and thrombocytosis occur. In the convalescent stage,
the child appears normal, but signs of inflammation may be present.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Inflammation
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
1.Weighing the diapers
2.Inserting a urinary catheter
3.Comparing intake with output
4.Measuring the amount of water added to formula
1. Rationale:
Heart failure is the inability of the heart to pump a sufficient
amount of blood to meet the oxygen and metabolic needs of the body.
The most appropriate method for assessing urine output in an infant
receiving diuretic therapy is to weigh the diapers. Comparing intake
with output would not provide an accurate measure of urine output.
Measuring the amount of water added to formula is unrelated to the
amount of output. Although urinary catheter drainage is most accurate
in determining output, it is not the most appropriate method in an
infant and places the infant at risk for infection.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Comparable or Alike Options, Strategic Words
Priority Concepts: Clinical Judgment, Perfusion
The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
1.Pallor
2.Hyperactivity
3.Exercise intolerance
4.Gastrointestinal disturbances
3.Rationale:
Aortic stenosis is a narrowing or stricture of the aortic valve,
causing resistance to blood flow in the left ventricle, decreased
cardiac output, left ventricular hypertrophy, and pulmonary vascular
congestion. A child with aortic stenosis shows signs of exercise
intolerance, chest pain, and dizziness when standing for long periods.
Pallor may be noted, but is not specific to this type of disorder
alone. Options 2 and 4 are not related to this disorder.
Cognitive Ability: Analyzing
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process:
Assessment
Content Area: Pediatrics:
Cardiovascular
Strategy(ies): Subject
Priority Concepts:
Elimination, Perfusion
The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?
1."A balance of rest and exercise is important."
2."I can apply lotion or powder to the incision if it is itchy."
3."Activities in which my child could fall need to be avoided for 2 to 4 weeks."
4."Large crowds of people need to be avoided for at least 2 weeks after surgery."
2. Rationale:
The mother should be instructed that lotions and powders should not
be applied to the incision site after cardiac surgery. Lotions and
powders can irritate the surrounding skin, which could lead to skin
breakdown and subsequent infection of the incision site. Options 1, 3,
and 4 are accurate instructions regarding home care after cardiac surgery.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Negative Event Query, Strategic Words
Priority Concepts: Client Education, Health Promotion
A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
1. "Has the child complained of back pain?"
2."Has the child complained of headaches?"
3."Has the child had any nausea or vomiting?"
4."Did the child have a sore throat or fever within the last 2 months?"
4.Rationale:
Rheumatic fever is an inflammatory autoimmune disease that affects
the connective tissues of the heart, joints, skin (subcutaneous
tissues), blood vessels, and central nervous system. Rheumatic fever
characteristically manifests 2 to 6 weeks after an untreated or
partially treated group A β-hemolytic streptococcal infection of the
upper respiratory tract. Initially, the nurse determines whether the
child had a sore throat or an unexplained fever within the past 2
months. Options 1, 2, and 3 are unrelated to rheumatic fever.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Inflammation
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?
1.During sleep
2.When changing the infant's diapers
3.When the mother is holding the infant
4.When drawing blood for electrolyte level testing
4.Rationale:
Heart failure (HF) is the inability of the heart to pump a
sufficient amount of blood to meet the oxygen and metabolic needs of
the body. Crying exhausts the limited energy supply, increases the
workload of the heart, and increases the oxygen demands. Oxygen
administration may be prescribed for stressful periods, especially
during bouts of crying or invasive procedures. Options 1, 2, and 3 are
not likely to produce crying in the infant.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Perfusion
The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position?
1.Prone position
2.Knee-chest position
3.High Fowler's position
4.Reverse Trendelenburg's position
2. Rationale:
Tetralogy of Fallot includes four defects–ventricular septal defect,
pulmonary stenosis, overriding aorta, and right ventricular
hypertrophy. If pulmonary vascular resistance is higher than systemic
resistance, the shunt is from right to left; if systemic resistance is
higher than pulmonary resistance, the shunt is left to right. If a
hypercyanotic spell occurs, the nurse immediately places the infant in
a knee-chest position. This position improves systemic arterial oxygen
saturation. All other options will not improve systemic arterial
oxygen saturation.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Strategic Words, Subject
Priority Concepts: Gas Exchange, Perfusion
The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider?
1.Bradypnea
2.Diaphoresis
3.Decreased blood pressure
4.A weight gain of 1 lb (0.5 kg) in 1 day
4.Rationale:
Heart failure (HF) is the inability of the heart to pump a
sufficient amount of oxygen to meet the metabolic needs of the body. A
weight gain of 1 lb (0.5 kg ) in 1 day is caused by the accumulation
of fluid. The nurse should assess urine output, assess for evidence of
facial or peripheral edema, auscultate lung sounds, and report the
weight gain to the health care provider. Tachypnea and increased blood
pressure occur with fluid accumulation. Diaphoresis is a sign of HF,
but it is not specific to fluid accumulation and usually occurs with
exertional activities.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Analysis
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Gas Exchange, Perfusion
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation?
1.Anxiety
2.A temper tantrum
3.A hypercyanotic episode
4.The need for immediate health care provider notification
3.Rationale:
Children with tetralogy of Fallot or similar physiology may
experience hypercyanotic episodes, or tet spells. These episodes are
characterized by increased respiratory rate and depth and increased
hypoxia. Immediate health care provider (HCP) notification is not
required unless other appropriate nursing interventions are
unsuccessful. Anxiety and a temper tantrum are unrelated to tetralogy
of Fallot.
Cognitive Ability: Analyzing
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process:
Analysis
Content Area: Pediatrics:
Cardiovascular
Strategy(ies): Subject
Priority Concepts:
Clinical Judgment, Gas Exchange
The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother?
1."The child may return to school in 1 week."
2."The child will not be able to return to school during this academic year."
3."The child may return to school in 1 week but needs to go half-days for the first 2 weeks."
4."The child may return to school in 3 weeks but needs to go half-days for the first few days."
4.Rationale:
After heart surgery, the child may be able to return to school
in 3 weeks but needs to go half-days for the first few days. The
mother also should be told that that the child cannot participate in
physical education for 2 months. The remaining options are incorrect.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Comparable or Alike Options, Strategic Words
Priority Concepts: Infection, Safety
A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child?
1.Elevated antistreptolysin O titer
2.Decreased erythrocyte sedimentation rate
3.Negative result on antinuclear antibody assay
4.Negative result on C-reactive protein determination
1.Rationale:
In the presence of rheumatic fever, the child will exhibit an
elevated antistreptolysin O titer, an elevated erythrocyte
sedimentation rate, leukocytosis, and a positive result on C-reactive
protein determination. A positive result on antinuclear antibody
testing is used to diagnose a wide variety of connective-tissue,
vascular, and immune complex disorders and also will be positive with
rheumatic fever.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Analysis
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Infection
A 12-year-old is admitted to the hospital with a low-grade fever and
joint pain. Which diagnostic test finding will assist to determine a
diagnosis of rheumatic fever?
1.Absence of C-reactive protein
2.Presence of Reed-Sternberg cells
3.Decreased antistreptolysin O titer
4.Elevated erythrocyte sedimentation rate
4.Rationale:
Rheumatic fever develops after a group A beta- hemolytic
streptococcal infection, particularly pharyngitis. Initial diagnosis
is made by noting the presence of Aschoff's bodies, or hemorrhagic
bullous lesions, in the heart, joints, skin, and central nervous
system; an elevated antistreptolysin O titer; an elevated C-reactive
protein level; and an elevated erythrocyte sedimentation rate.
Reed-Sternberg cells are found in Hodgkin's disease.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Analysis
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Infection
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply.
1.Elevated C-reactive protein
2.Elevated antistreptolysin O titer
3.Presence of Reed-Sternberg cell
4.Decreased erythrocyte sedimentation rate
5.Presence of group A beta-hemolytic strep
1,2,5 Rationale:
Rheumatic fever usually develops after a group A beta-hemolytic
streptococcal infection, particularly pharyngitis. Initial diagnosis
is made by noting the presence of Aschoff's bodies, or hemorrhagic
bullous lesions, in the heart, joints, skin, and central nervous
system; an elevated C-reactive protein level; an elevated
antistreptolysin O titer; and an elevated erythrocyte sedimentation
rate. Reed-Sternberg cells are found in Hodgkin's disease.
Cognitive Ability: Analyzing
Client Needs: Physiological
Integrity
Integrated Process: Nursing Process:
Analysis
Content Area: Pediatrics:
Cardiovascular
Strategy(ies): Subject
Priority Concepts:
Evidence, Infection
A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action?
1.Retake the apical pulse.
2.Withhold the medication.
3.Administer the medication.
4. Notify the health care provider.
3.Rationale:
The apical pulse rate for a 1-year-old infant is 90 to 130
beats/min. Because the apical rate is normal, the remaining options
are incorrect.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject, Data in the Question
Priority Concepts: Clinical Judgment, Safety
The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?
1.Retake the apical pulse
2..Administer the medication.
3.Withhold the medication for 1 hour.
4.Withhold the medication and notify the health care provider.
4. Rationale:
The apical pulse rate for a
newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges
from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate
is low and the digoxin blood level is elevated, indicating toxicity,
the nurse would withhold the medication and notify the health care
provider. Therefore, the remaining options are incorrect.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Subject, Data in the Question
Priority Concepts: Clinical Judgment, Safety
The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action?
1.Withhold the medication.
2.Administer the medication.
3.Check the blood pressure and then administer the medication.
4.Check the respiratory rate and then administer the medication.
1. Rationale:
Digoxin is a cardiac glycoside that is used to treat heart
failure. A primary concern is digoxin toxicity, and the nurse needs to
monitor closely for signs of toxicity and monitor digoxin blood
levels. The medication is effective within a narrow therapeutic
digoxin range (0.5 to 0.8 ng/mL). Safety in administration is achieved
by double-checking the dose and counting the apical heart rate for 1
full minute. The apical pulse rate for an infant is 90 to 130
beats/min If the heart rate is less than 90 beats/minute in an infant,
the nurse would withhold the dose and contact the health care
provider. Therefore, the remaining options are incorrect actions; it
would be harmful to administer the medication.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Comparable or Alike Options, Subject
Priority Concepts: Clinical Judgment, Safety
The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition?
1.Bleeding
2.Heart failure
3.Failure to thrive
4.Decreased tolerance to stimulation
2.Rationale:
Nursing care initially centers on observing for signs of heart
failure. The nurse monitors for increased respiratory rate, increased
heart rate, dyspnea, crackles, and abdominal distension. The remaining
options are not conditions directly associated with this disorder.
Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Strategic Words, Subject
Priority Concepts: Clinical Judgment, Perfusion
The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate?
1.Administer acetaminophen for temperature elevation.
2.Administer the aspirin if the child's temperature is elevated.
3.Administer the aspirin if the child experiences any joint pain.
4.Consult with the health care provider to verify the prescription.
4.Rationale:
Antiinflammatory agents, including aspirin, may be prescribed for
the child with rheumatic fever. Aspirin should not be given to a child
who has chickenpox or other viral infections because of the risk of
Reye's syndrome. Therefore, the nurse should consult with the health
care provider (HCP) to verify the prescription. The nurse would not
administer acetaminophen without specific HCP prescriptions.
Administering aspirin is not an appropriate action without consulting
the HCP first.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Pediatrics: Cardiovascular
Strategy(ies): Strategic Words, Comparable or Alike Options
Priority Concepts: Clinical Judgment, Safety
The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure?
1.Paleness of the skin
2.Strong sucking reflex
3.Diaphoresis during feeding
4.Slow and shallow breathing
3.Rationale:
The early symptoms of heart failure (HF) include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.
The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?
1.Severe bradycardia
2.Asymptomatic after feeding
3.Bluish discoloration of the skin
4.Higher than normal body weight
3.Rationale:
The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Severe bradycardia and asymptomatic after feedings are inaccurate findings. Many children with a left-to-right shunt may remain asymptomatic. High body weight is incorrect because these children usually have lower than normal body weight.
The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia?
1.Tachypnea
2.Tachycardia
3.Sucking on the fingers
4.Clubbing of the fingers
4. Rationale
The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Tachypnea and tachycardia are signs of acute hypoxia. Sucking on the fingers may indicate hunger or irritability. Further assessment is needed to determine if this behavior is due to congenital heart disease.
A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching?
1."Quiet activities are allowed."
2."The child should play inside for now."
3."Visitors are not allowed for 1 month."
4."The regular schedule for naps is resumed."
3.Rationale:
Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge. The remaining options are accurate instructions regarding activity following heart surgery.