Question 1

The nurse is caring for a newborn diagnosed with patent ductus arteriosus. Which finding will the nurse assess that is consistent with this diagnosis?

Accepted Answer

On physical examination, the child with patent ductus arteriosus usually has a wide pulse pressure. The diastolic pressure is low because of the shunt or runoff of blood, which reduces resistance. Manifestations of patent ductus arteriosus do not include a slow heart rate, expiratory grunt, or absent femoral pulses.

Question 2

Which of the following nursing diagnoses would best apply to a child during the acute phase of rheumatic fever?

Accepted Answer

The course of rheumatic fever is about 6 to 8 weeks. Children are maintained on bed rest only during the acute phase of illness until the pulse rate returns to normal. Because pulse rate is a valuable sign of improvement, monitoring vital signs is essential during and following the acute phase. Obtain an apical pulse for a full minute for best results. Taking it while the child is asleep as well as when the child is awake helps to measure the effect of activity on the pulse rate; another way to judge inflammation is decreasing and the child's heart action is improving. Chorea occurs in some children with rheumatic fever; however, it is not known if this manifestation will disturb the child's sleep.
Children with rheumatic fever may develop congestive heart failure; however, cardiomegaly is not a long-term effect of the disease. The child is not at risk for self-directed violence because cerebral anoxia is not a manifestation of the disease.

Question 3

The nurse is planning a program for community family members that focuses on the 2020 National Health Goals to improve cardiovascular health. Which content should the nurse include in this program? (Select all that apply.)

Accepted Answer

Nurses can help the nation achieve the 2020 National Health Goals by educating parents and children about the importance of reducing obesity and planning exercise and nutrition programs for sound cardiovascular health. Parents should be cautioned not to start their children on reduced-fat diets until they are 2 years old to allow for myelination of nerve cells. Stress-reduction activities are not identified as actions to achieve the 2020 National Health Goals for cardiovascular health.

Question 4

A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant?

Accepted Answer

If the coarctation is slight, absence of palpable femoral pulses from the decreased blood pressure in the lower body may be the only symptom seen. To help detect this, the nurse should always include evaluation of femoral pulses in all initial newborn assessments and admission inspections to newborn nurseries. Excessive crying, cardiac murmur, and blood pressure changes are not manifestations of coarctation of the aorta.

Question 5

What should the nurse teach the parents of a child with tetralogy of Fallot to do if the child suddenly becomes cyanotic and dyspneic?

Accepted Answer

Parents need to try to keep hypercyanotic episodes to a minimum and learn what steps to take if one should occur. Placing the baby in a knee-chest position to trap blood in the lower extremities and keep the heart from being overwhelmed generally reduces symptoms. Lying prone, supine, or in the semi-Fowler's position will not help reduce cyanosis and dyspnea.

Question 6

Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder?

Accepted Answer

Hydration must be monitored so dehydration does not occur in children with polycythemia so the polycythemia does not become so severe clotting or thrombophlebitis results. Seizures are not a threat with polycythemia. Jaundice is not associated with polycythemia. Encourage parents to observe the infant carefully when new activities are introduced so they can recognize the first signs of respiratory distress or the point at which the child is beginning to exceed exercise tolerance.

Question 7

The nurse instructs the parents of a child with a congenital heart disorder on the administration of digoxin at home. Which observation indicates that teaching has been effective?

Accepted Answer

Guidelines to ensure safe digoxin administration at home include providing a dose of the medication 1 hour before the next scheduled feeding. If a dose is vomited, do not repeat the dose. The medication should be given 2 hours after a feeding and not immediately after. The apical heart rate and not the radial pulse should be assessed before providing a dose of the medication.

Question 8

The parents of a child having a cardiac catheterization are waiting to see the child after the procedure. What should the nurse instruct the parents to expect when seeing the child for the first time?

Accepted Answer

When a child returns from a cardiac catheterization, a pressure dressing will be present over the catheter insertion site. This dressing is snug and will be checked to ensure that no bleeding is occurring. The child may or may not be sleepy after the procedure. The child will not have bruising over the upper and lower extremities. Seizure precautions are not necessary after a cardiac catheterization.

Question 9

The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient?

Accepted Answer

Ventricular septal defect is the most common type of congenital cardiac disorder. With this disorder, an opening is present in the septum between the two ventricles. Blood shunts from left to right across the septum impairing the efficiency of the heart because blood that should be forced into the aorta and out to the body from contraction of the left ventricle shunts back into the pulmonary circulation, resulting in right ventricular hypertrophy and increased pressure in the pulmonary artery. This disorder does not impair gas exchange, cause impaired skin integrity, or cause ineffective airway clearance.

Question 10

An infant is prescribed digoxin. What should the nurse explain to the parents regarding the action of this medication?

Accepted Answer

Digoxin, a cardiac glycoside made from digitalis, acts directly on the heart to increase the contractility of the myocardium and the force of contraction to slow the heart rate. Digoxin does not increase the heart rate, thicken the walls of the myocardium, or prevent subacute bacterial endocarditis.

Question 11

The nurse is assessing the heart rate of a child with a congenital heart defect. What should the nurse document when a pulse of one strong beat and one weak beat is assessed?

Accepted Answer

Pulsus alternans is a pulse of one strong beat and one weak beat. Dicrotic pulse is a double radial pulse for every apical beat. Thready pulse is weak and usually rapid. Water hammer pulse is very forceful and bounding with capillary pulsations apparent even in the fingernails.

Question 12

Which action should the nurse implement for an infant who develops heart failure?

Accepted Answer

Most children with heart failure feel more comfortable in a semi-Fowler's position than in a supine position because the chest-elevated position lowers the abdominal contents, enlarging the thoracic cavity and allowing easier, more comfortable lung expansion. A child with heart failure does not need a milk restriction. The supine position will not help with lung expansion. An infant does not have a significant intake of salt.

Question 13

The nurse is caring for a child with chest tubes inserted after heart surgery that are attached to an underwater-seal drainage system. For which reason should the nurse prepare to clamp the chest tubes?

Accepted Answer

If a tube becomes disconnected creating an air leak, clamp the tube close to the child's chest to prevent further air from entering the chest. The chest tube should not be clamped if the child is coughing, a clot is in the tubing, or red-stained drainage appears in the tube.

Question 14

The cardiac monitor of a child recovering from heart surgery alarms, and the nurse finds the child without a heartbeat. What should the nurse do first?

Accepted Answer

The steps for resuscitation can be remembered as "CAB"-chest compressions, airway, and breathing-and the critical first elements of cardiopulmonary resuscitation are chest compressions and early defibrillation. Establishing an airway, rescue breathing, and the use of oxygen are performed in sequence after compressions are started.

Question 15

A toddler is diagnosed with a functional heart murmur. What should the nurse explain to the child's parents about this murmur?

Accepted Answer

Murmurs of no significance are termed functional, insignificant, or innocent murmurs. In discussing such murmurs with parents, the term innocent heart murmur is best to use because it most clearly describes that the sound heard is not important or is nothing to worry about. Activity restrictions, frequent health appraisals, and corrective surgery are not indicated for a functional heart murmur.

Quiz 41: Nursing Care of a Family When a Child Has a Cardiovascular Disorder