The Child with a Cardiovascular Alteration

MULTIPLE CHOICE

1. A nurse is conducting a class for nursing students about fetal circulation. Which statement is accurate about fetal circulation and should be included in the teaching session?

a.
Oxygen is carried to the fetus by the umbilical arteries.
b.
Blood from the inferior vena cava is shunted directly to the right ventricle through the foramen ovale.
c.
Pulmonary vascular resistance is high because the lungs are filled with fluid.
d.
Blood flows from the ductus arteriosus to the pulmonary artery.

ANS: C

Resistance in the pulmonary circulation is very high because the lungs are collapsed and filled with fluid. Oxygen and nutrients are carried to the fetus by the umbilical vein. The inferior vena cava empties blood into the right atrium. The direction of blood flow and the pressure in the right atrium propel most of this blood through the foramen ovale into the left atrium. Most of the blood in the pulmonary artery flows though the ductus arteriosus into the descending aorta.

DIF: Cognitive Level: Application REF: pp. 532-533

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. Which postoperative intervention should be questioned for a child after a cardiac catheterization?

a.
Continue intravenous (IV) fluids until the infant is tolerating oral fluids.
b.
Check the dressing for bleeding.
c.
Assess the peripheral circulation on the affected extremity.
d.
Keep the affected leg flexed and elevated.

ANS: D

The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity.

DIF: Cognitive Level: Application REF: p. 546

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

3. Which information should be included in the nurse’s discharge instructions for a child who underwent a cardiac catheterization earlier in the day?

a.
The pressure dressing is changed daily for the first week.
b.
The child may soak in the tub beginning tomorrow.
c.
Contact sports can be resumed in 2 days.
d.
The child can return to school on the third day after the procedure.

ANS: D

The child can return to school on the third day after the procedure. It is important to emphasize follow-up with the cardiologist. The day after the cardiac catheterization, the pressure dressing is removed and replaced with a Band-Aid. The catheter insertion site is assessed daily for healing. Any bleeding or sign of infection, such as drainage, must be reported to the cardiologist. Bathing is limited to a shower, sponge bath, or a brief tub bath (no soaking) for the first 1 to 3 days after the procedure. Strenuous exercise such as contact sports, swimming, or climbing trees is avoided for up to 1 week after the procedure.

DIF: Cognitive Level: Application REF: pp. 546-547

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

4. A nurse is preparing to assess a 9-month-old infant admitted to the hospital for further evaluation of an atrial septal defect (ASD). Which should the nurse do first for the cardiac assessment?

a.
Percussion
b.
Palpation
c.
Auscultation
d.
History and inspection

ANS: D

The assessment should begin with the least threatening interventions—the history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. Percussion of the chest is usually deferred. Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. Auscultation requires touching the child and is not the initial step in a cardiac assessment.

DIF: Cognitive Level: Application REF: p. 544

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

5. In which situation is there a risk that a newborn infant will have a congenital heart defect (CHD)?

a.
Trisomy 21 detected on amniocentesis
b.
Family history of myocardial infarction
c.
Father has type 1 diabetes mellitus
d.
Older sibling was born with Turner’s syndrome

ANS: A

The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner’s syndrome, have a higher incidence of CHD. A family history is not a risk factor.

DIF: Cognitive Level: Comprehension REF: p. 535

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

6. Before giving a dose of digoxin (Lanoxin), the nurse checked an infant’s apical heart rate and it is 114 beats per minute. What should the nurse do next?

a.
Administer the dose as ordered.
b.
Hold the medication until the next dose.
c.
Wait and recheck the apical heart rate in 30 minutes.
d.
Notify the physician about the infant’s heart rate.

ANS: A

The infant’s heart rate is above the lower limit for which the medication is held. The dose can be given. It is unnecessary to recheck the heart rate at a later time. A dose of Lanoxin is withheld for a heart rate less than 100 beats per minute in an infant and a physician should be notified.

DIF: Cognitive Level: Application REF: p. 538

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

7. Which intervention should be included in the plan of care for an infant with the nursing diagnosis Fluid volume excess related to congestive heart failure?

a.
Weigh the infant every day on the same scale at the same time.
b.
Notify the physician when weight gain exceeds more than 20 g/day.
c.
Put the infant in a car seat to minimize movement.
d.
Administer digoxin (Lanoxin) as ordered by the physician.

ANS: A

Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant’s position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid.

DIF: Cognitive Level: Application REF: p. 538

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

8. The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect?

a.
Pulmonary stenosis
b.
Patent ductus arteriosus
c.
Ventricular septal defect
d.
Coarctation of the aorta

ANS: B

The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, harsh holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present.

DIF: Cognitive Level: Comprehension REF: p. 548

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

9. Which is an expected assessment finding in a child with coarctation of the aorta?

a.
Orthostatic hypotension
b.
Systolic hypertension in the lower extremities
c.
Blood pressure higher on the left side of the body
d.
Disparity in blood pressure between the upper and lower extremities

ANS: D

The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation.

DIF: Cognitive Level: Comprehension REF: p. 551

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

10. A nurse is assessing an infant with chronic hypoxia due to tetralogy of Fallot. Which finding does the nurse expect to assess?

a.
Polycythemia
b.
Pulmonary hypotension
c.
Dehydration
d.
Anemia

ANS: A

The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Pulmonary hypertension is a clinical consequence of cyanosis. Dehydration can occur rapidly in cyanotic heart disease. It is not a compensatory mechanism to chronic hypoxia. Anemia may develop as a result of increased blood viscosity.

DIF: Cognitive Level: Analysis REF: p. 542

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

11. Which statement made by a parent indicates understanding of activity restrictions for a child after cardiac surgery?

a.
“My child needs to get extra rest for a few weeks.”
b.
“My son is really looking forward to riding his bike next week.”
c.
“I’m so glad we can attend services as a family this coming Sunday.”
d.
“I am going to keep my child out of day care for 6 weeks.”

ANS: D

Settings in which large groups of people are present should be avoided for 4 to 6 weeks after discharge, including day care. The child should resume his regular bedtime and sleep schedule after discharge. Activities during which the child could fall, such as riding a bicycle, are avoided for 4 to 6 weeks after discharge. Large crowds of people should be avoided for 4 to 6 weeks after discharge, including public worship.

DIF: Cognitive Level: Application REF: p. 557

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

12. A child had a ventricular septal defect surgically repaired 3 months ago. Which antibiotic prophylaxis is indicated for an upcoming dental procedure?

a.
No antibiotic prophylaxis is necessary.
b.
Amoxicillin is taken orally 1 hour before the procedure.
c.
Oral penicillin is given for 7 to 10 days before the procedure.
d.
Parenteral antibiotics are administered for 4 to 8 weeks after the procedure.

ANS: B

The standard prophylactic agent is amoxicillin given orally 1 hour before the procedure. Antibiotic prophylaxis is indicated for the first 6 months after surgical repair. Antibiotic prophylaxis is not given for this period of time. The treatment for infective endocarditis involves parenteral antibiotics for 4 to 8 weeks.

DIF: Cognitive Level: Application REF: p. 558

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

13. A nurse is assessing a 7-day-old infant. The nurse detects a soft murmur. The nurse notifies the primary care physician because the nurse is aware that fetal shunts are closed in the infant at what point in time?

a.
When the umbilical cord is cut
b.
Within several days of birth
c.
Within a month after birth
d.
By the end of the first year of life

ANS: B

In the normal neonate, fetal shunts functionally close in response to pressure changes in the systemic and pulmonary circulations and to increased oxygen content. This process may take several days to complete. With the neonate’s first breath, gas exchange is transferred from the placenta to the lungs. The separation of the fetus from the umbilical cord does not contribute to the establishment of neonatal circulation.

DIF: Cognitive Level: Implementation REF: p. 534

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

14. When assessing a child for possible congenital heart defects, where should the nurse measure blood pressure?

a.
The right arm
b.
The left arm
c.
All four extremities
d.
Both arms while the child is crying

ANS: C

When a congenital heart defect is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements when the child is crying are likely to be elevated; thus, the readings will be inaccurate. Blood pressure measurements for upper and lower extremities are compared during an assessment for congenital heart defects.

DIF: Cognitive Level: Implementation REF: p. 545

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

15. What should be the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect?

a.
Assess the parents’ readiness to learn.
b.
Gather literature for the parents.
c.
Secure a quiet place for teaching.
d.
Discuss the plan with the nursing team.

ANS: A

Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents’ knowledge and readiness.

DIF: Cognitive Level: Comprehension REF: p. 539|p. 543

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

16. A nurse is explaining a patent ductus arteriosus defect to the parents of a preterm infant. The parents indicate understanding of the defect when they state that a patent ductus arteriosus:

a.
involves a defect that results in a right-to-left shunting of blood in the heart.
b.
involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close.
c.
is a stenotic lesion that must be surgically corrected at birth.
d.
causes an abnormal opening between the four chambers of the heart.

ANS: B

Patent ductus arteriosus is failure of the fetal shunt between the aorta and the pulmonary artery to close. A patent ductus arteriosus allows blood to flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Patent ductus arteriosus is not a stenotic lesion. Patent ductus arteriosus can be closed both medically and surgically. Atrioventricular defect occurs when fetal development of the endocardial cushions is disturbed, resulting in abnormalities in the atrial and ventricular septa and the atrioventricular valves.

DIF: Cognitive Level: Comprehension REF: p. 548

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

17. Why might a newborn infant with a cardiac defect, such as coarctation of the aorta resulting in a right-to-left shunt, receive prostaglandin E1?

a.
To decrease inflammation
b.
To control pain
c.
To decrease respirations
d.
To keep the ductus arteriosus patent

ANS: D

Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent to increase pulmonary blood flow.

DIF: Cognitive Level: Comprehension REF: p. 551

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

18. Which congenital heart defect results in increased pulmonary blood flow?

a.
Ventricular septal defect
b.
Coarctation of the aorta
c.
Tetralogy of Fallot
d.
Pulmonary stenosis

ANS: A

Ventricular septal defect causes a left-to-right shunting of blood, thus increasing pulmonary blood flow. Coarctation of the aorta is a stenotic lesion that causes increased resistance to blood flow from the proximal to distal aorta. The defects associated with tetralogy of Fallot result in a right-to-left shunting of blood, thus decreasing pulmonary blood flow. Pulmonary stenosis causes obstruction of blood flow from the right ventricle to the pulmonary artery. Pulmonary blood flow is decreased.

DIF: Cognitive Level: Comprehension REF: p. 549

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

19. Which statement suggests that a parent understands how to correctly administer digoxin?

a.
“I measure the amount I am supposed to give with a measuring spoon.”
b.
“I put the medicine in the baby’s bottle.”
c.
“When she spits up right after I give the medicine, I give her another dose.”
d.
“I give the medicine at 8 in the morning and evening every day.”

ANS: D

For maximum effectiveness, the medication should be given at the same time every day and should be measured with a syringe. The medication should not be mixed with formula or food. It is difficult to judge whether the child received the proper dose if the medication is placed in food or formula. To prevent toxicity, the parent should not repeat the dose without contacting the child’s physician.

DIF: Cognitive Level: Application REF: p. 541

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

20. What nursing action is appropriate to take when an infant with a congenital heart defect has an increased respiratory rate and sweating and is not feeding well?

a.
Check the infant’s temperature.
b.
Alert the physician.
c.
Withhold oral feeding.
d.
Increase the oxygen rate.

ANS: B

An increased respiratory rate, sweating, and not feeling well are signs of early congestive heart failure and the physician should be notified; they do not suggest a febrile process. Withholding the infant’s feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms, but medications such as digoxin and furosemide are necessary to improve heart function and fluid retention.

DIF: Cognitive Level: Analysis REF: p. 538

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

21. Nursing care for the child in congestive heart failure includes which action?

a.
Counting the number of saturated diapers
b.
Putting the infant in the Trendelenburg position
c.
Removing oxygen while the infant is crying
d.
Organizing care to provide rest periods

ANS: D

Nursing care should be planned to allow for periods of undisturbed rest. Diapers must be weighed for an accurate record of output. The head of the bed should be raised to decrease the work of breathing. Oxygen should be administered during stressful periods such as when the child is crying.

DIF: Cognitive Level: Application REF: p. 538

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

22. Which strategy is appropriate when feeding the infant with congestive heart failure?

a.
Continue the feeding until a sufficient amount of formula is taken.
b.
Limit feedings to no more than 30 minutes.
c.
Always bottle feed every 4 hours.
d.
Feed larger volumes of concentrated formula less frequently.

ANS: B

The infant with congestive heart failure may tire easily so the feeding should not continue beyond 30 minutes. If inadequate amounts of formula are taken, gavage feedings should be considered. Infants with congestive heart failure may be breast-fed or fed a smaller volume of concentrated formula. Feedings every 3 hours is a frequently used interval. If the infant were fed less frequently than every 3 hours, more formula would need to be consumed and would tire the infant.

DIF: Cognitive Level: Application REF: p. 539

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

23. A nurse is teaching an adolescent about primary hypertension. Which statement made by the adolescent indicates an understanding about primary hypertension?

a.
Primary hypertension should be treated with diuretics as soon as it is detected.
b.
Congenital heart defects are the most common cause of primary hypertension.
c.
Primary hypertension may be treated with weight reduction.
d.
Primary hypertension is not affected by exercise.

ANS: C

Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacological intervention may be needed. Primary hypertension is considered to be an inherited disorder.

DIF: Cognitive Level: Comprehension REF: p. 566

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

24. A nurse is planning care for a child with secondary hypertension. The nurse plans to include which initial treatment of secondary hypertension?

a.
Weight control and diet
b.
Treating the underlying disease
c.
Administration of digoxin
d.
Administration of beta-adrenergic receptor blockers

ANS: B

Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are a nonpharmacological treatment for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. Beta-adrenergic receptor blockers are indicated in the treatment of primary hypertension.

DIF: Cognitive Level: Application REF: p. 567

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

25. Which should the nurse include in discharge teaching for the child with a cardiac arrhythmia?

a.
CPR instructions
b.
Repeating digoxin if the child vomits
c.
Resting if dizziness occurs
d.
Checking the child’s pulse after digoxin administration

ANS: A

The parents and significant others in the child’s life should have CPR training. The digoxin dose is not repeated if the child vomits. Dizziness is a symptom the child should be taught to report to adults so the physician can be notified. The child’s pulse should be counted before the medication is given. The dose is withheld if the pulse is below the parameters set by the physician.

DIF: Cognitive Level: Comprehension REF: p. 561

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

26. A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic?

a.
Place the infant in a knee-chest position.
b.
Administer oxygen.
c.
Administer morphine sulfate.
d.
Notify the physician.

ANS: A

Placing the infant in a knee-chest position will decrease venous return so that smaller amounts of highly saturated blood reach the heart. Administering oxygen is indicated after placing the infant in a knee-chest position. Administering morphine sulfate calms the infant. It is indicated after the infant has been placed in a knee-chest position. The physician should be notified after the infant has been placed in a knee-chest position.

DIF: Cognitive Level: Application REF: p. 542

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

27. The nurse caring for a child with a diagnosis of rheumatic fever should assess the child for which finding?

a.
Sore throat
b.
Elevated blood pressure
c.
Desquamation of the fingers and toes
d.
Tender, warm, inflamed joints

ANS: D

Arthritis, characterized by tender, warm, erythematous joints, is one of the major manifestations of rheumatic fever. The child may have had a sore throat previously associated with a group A beta-hemolytic streptococcal infection a few weeks earlier. A sore throat is not a manifestation of rheumatic fever. Hypertension is not associated with rheumatic fever. Desquamation of the fingers and toes is a manifestation of Kawasaki syndrome.

DIF: Cognitive Level: Comprehension REF: p. 563

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

28. A nurse is caring for a child admitted to the hospital with Kawasaki disease. Which cardiac complication of Kawasaki disease should the nurse monitor for?

a.
Cardiac valvular disease
b.
Cardiomyopathy
c.
Coronary aneurysm
d.
Rheumatic fever

ANS: C

Coronary aneurysm formation begins early in the second phase of Kawasaki syndrome. Coronary artery aneurysms are seen in 20% of children with untreated Kawasaki disease. Cardiac valvular disease can occur in rheumatic fever. Cardiomyopathies are diseases of the heart muscle, which can occur as a result of congenital heart disease, coronary artery disease, or other systemic disease. Rheumatic fever is not a complication of Kawasaki syndrome.

DIF: Cognitive Level: Comprehension REF: p. 564

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which congenital heart disease causes cyanosis when not repaired? Select all that apply.

a.
Patent ductus arteriosus (PDA)
b.
Tetralogy of Fallot
c.
Pulmonary atresia
d.
Transposition of the great arteries

ANS: B, C, D

Tetralogy of Fallot is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Pulmonary atresia is a cyanotic lesion with decreased pulmonary blood flow. The hypoxia results in baseline oxygen saturations as low as 75% to 85%. Even with oxygen administration, saturations do not reach the normal range. Transposition of the great arteries is a cyanotic lesion with increased pulmonary blood flow. PDA is failure of the fetal shunt between the aorta and the pulmonary artery to close. PDA is not classified as a cyanotic heart disease. Prostaglandin E1 is often given to maintain ductal patency in children with cyanotic heart diseases.

DIF: Cognitive Level: Analysis REF: p. 551

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

2. A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child’s parents? Select all that apply.

a.
Replace whole milk for 2% or 1% milk
b.
Increase servings of red meat
c.
Increase servings of fish
d.
Avoid excessive intake of fruit juices
e.
Limit servings of whole grain

ANS: A, C, D

A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats.

DIF: Cognitive Level: Application REF: p. 569

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

3. A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if which occurs? Select all that apply.

a.
Respiratory rate of 36 at rest
b.
Appetite slowly increasing
c.
Temperature above 37.7° C (100° F).
d.
New, frequent coughing
e.
Turning blue or bluer than normal

ANS: C, D, E

The parents should be instructed to notify the physician after their infant’s cardiac surgery for a temperature above 37.7° C; new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations and it is expected that the appetite will increase slowly.

DIF: Cognitive Level: Application REF: p. 557

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance