*Chapter 21 Alterations in Cardiac Function

An infant has been diagnosed with a small ventircular septal defect following detection of a murmur during a routine assessment. What anticipatory guidance should the nurse provide the infant's family?

The infant's growth and development will be hindered unless there is prompt treatment

The infant may be a candidate for a heart transplant

The infant will likely be prepared for emergency surgery

The infant's growth and development are unlikely to be affected

The infant's growth and development are unlikely to be affected

Rationale:Small, isolated defects are usually asymptomatic. Growth and development are usually unaffected and this is not a cardiac emergency needing immediate surgery or transplant.

A 5-year-old child has undergone a cardiac catheterization and is being prepared for discharge home with the parents. The nurse is teaching the parents how to care for the child at home. The nurse determines that the teaching is successful based on which statements by the parents? Select all that apply.

"If we notice any drainage or bleeding at the site, we will call the health care provider."

"Once our child is home, we don't need to check the temperature anymore."

"After several days, we don't need to keep any dressing on the site."

"If our child has pain, we can give acetaminiphen or ibuprofen."

"Our child should shower for about a week after the procedure."

"If we notice any drainage or bleeding at the site, we will call the health care provider."

"After several days, we don't need to keep any dressing on the site."

"If our child has pain, we can give acetaminiphen or ibuprofen."

Rationale:After a cardiac catheterization, the parents should change the pressure dressing on the day after the procedure and then apply a dry sterile dressing or adhesive bandage for the next several days. They should also inspect the insertion site for redness, irritation, swelling, drainage, and bleeding and report any of these to the health care provider. In addition, the parents should check the child's temperature at least once a day for approximately 3 days after the procedure and report any temperature elevation of 100.4ºF (38ºC) or greater. Tub baths are avoided for approximately 3 days after the procedure. Acetaminophen or ibuprofen may be used for reports of pain.

The nurse is implementing the plan of care for a child with acute rheumatic fever. What treatments would the nurse expect to administer if ordered? Select all that apply.

Digoxin

Intravenous immunoglobulin

Nonsteroidal anti-inflammatory drugs

Corticosteroids

Penicillin

Nonsteroidal anti-inflammatory drugs

Corticosteroids

Penicillin

Rationale:A full 10-day course of penicillin or equivalent is used. Corticosteroids are used as part of the treatment for acute rheumatic fever. Nonsteroidal anti-inflammatory drugs are used as part of the treatment for acute rheumatic fever. Digoxin is used to treat heart failure, atrial fibrillation, atrial flutter, and supraventricular tachycardia. Intravenous immunoglobulin is used to treat Kawasaki disease.

The nurse is caring for a child who has been experiencing hypercyanotic episodes. Which treatments will be effective in managing them? Select all that apply.

Assist the child to a knee chest position.

Reduce intravenous fluids.

Provide supplemental oxygen.

Administer Demerol as prescribed.

Apply a cool cloth the child's forehead.

Assist the child to a knee chest position.

Provide supplemental oxygen.

Rationale:When hypercyanotic episodes are encountered there are treatments that can be administered by the nurse to provide supportive care to the child. These interventions include providing supplemental oxygen. This measure promotes increased perfusion to the body. Placing the child in a knee-chest position will reduce workload on the heart and promotes perfusion. There is no reason to utilize a cloth to the child's head. Demerol is not administered. If medications are used, morphine would be the narcotic of choice. With hypercyanotic episodes intravenous fluids are increased not decreased.

Which of the following would be included in discharge teaching by the nurse of a child that had a patch placed surgically for an ASD?

Intake of 80 ounces of fluid daily

Need for frequent rest periods at home

Antibiotics should be administered before invasive procedures.

Teaching about how to take daily blood pressures

Antibiotics should be administered before invasive procedures.

Rationale:Antibiotics should be administered to prevent the risk of endocarditis. Consuming 80 ounces of fluid daily is too large of an amount. The need for frequent rest periods and daily blood pressures should not be necessary since the defect is repaired.

When caring for a child with Kawasaki disease, which of the following would the nurse expect to include in the child's plan of care? Select all that apply.

Providing a low-fiber diet

Administration of high-dose aspirin therapy

Performing active range-of-motion exercises

Assessing for signs and symptoms of bleeding

Administration of intravenous gamma globulin (IVIG)

Administration of high-dose aspirin therapy

Assessing for signs and symptoms of bleeding

Administration of intravenous gamma globulin (IVIG)

Rationale:Kawasaki disease is managed with IVIG and aspirin to prevent cardiac complications. The nurse should be alert for signs and symptoms of bleeding related to aspirin therapy. Joint pain may limit the child's mobility requiring comfort measures. Passive range of motion exercises are appropriate if joint pain is present. Frequent oral care and a clear liquid diet are provided to minimize mucous membrane pain.

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

Expiratory grunt

Absent femoral pulses

Slow heart rate

Wide pulse pressure

Wide pulse pressure

Rationale: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.

A nurse is administering digoxin to a 3-year-old child. The nurse decides to withhold the medication based on assessment of which of the following?

Vomiting

Hypertension

Ataxia

Fever

Vomiting

Rationale:Nausea and vomiting are signs of digoxin toxicity. Ataxia, hypertension, and fever are not associated with digoxin toxicity.

The nurse is assessing a child with aortic stenosis. Which findings would the nurse most likely assess? Select all that apply.

Thrill palpated at base of heart

Chest pain with activity

Moderately loud systolic murmur at the base of the heart

Blood pressure in arms significantly higher than in legs

Dizziness with prolonged standing

Thrill palpated at base of heart

Chest pain with activity

Dizziness with prolonged standing

Rationale: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 and blood pressure that is significantly higher in the arms than in the legs, possibly 20 mm Hg or higher, suggests coarctation of the aorta.

While assessing a neonate with a ventricular septal defect (VSD), the nurse notes crackles and retractions. The nurse obtains the following vital signs: temp 100.2°F (38°C), pulse 134 bpm, respirations 64 breaths/minute, oxygen saturation 97% on room air. What will the nurse do first?

Apply oxygen 10 lpm via oxyhood.

Advise the mother to bottle feed.

Give furosemide intravenously.

Administer acetaminophen rectally

Give furosemide intravenously.

Rationale:The nurse's first action when a neonate with a cardiac disorder is experiencing signs of fluid overload but has a normal oxygen saturation is to administer a diuretic, such as furosemide. Oxygen could be applied if the furosemide was not effective in reducing fluid overload or if the oxygen saturation was low. This will remove fluid from the lungs, allowing the infant to breathe more easily. Although the neonate has an elevated temperature, administration of acetaminophen does not take priority over breathing. If the neonate continues to show signs of pulmonary overload, the nurse could advise the mother to give expressed breastmilk through a bottle or nasogastric tube.

A chest radiography examination is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the x-ray show about the heart? The nurses response should be based on knowledge that the radiograph provides which information?

a. Shows bones of the chest but not the heart

b. Evaluates the vascular anatomy outside of the heart

c. Shows a graphic measure of electrical activity of the heart

d. Supplies information on heart size and pulmonary blood flow patterns

ANS: D

Chest radiographs provide information on the size of the heart and pulmonary blood flow patterns. The bones of the chest are visible on chest radiographs, but the heart and blood vessels are also seen. Magnetic resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the heart. A graphic measure of electrical activity of the heart is provided by electrocardiography

A 6-year-old child is scheduled for a cardiac catheterization. What consideration is most important in planning preoperative teaching?

a. Preoperative teaching should be directed at his parents because he is too young to understand.

b. Preoperative teaching should be adapted to his level of development so that he can understand.

c. Preoperative teaching should be done several days before the procedure so he will be prepared.

D. Preoperative teaching should provide details about the actual procedures so he will know what to expect.

ANS: B

Preoperative teaching should always be directed to the childs stage of development. The caregivers also benefit from these explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group will not understand in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization

After returning from cardiac catheterization, the nurse monitors the childs vital signs. The heart rate should be counted for how many seconds?

a. 15

b. 30

c. 60

d. 120

ANS: C

The heart rate is counted for a full minute to determine whether arrhythmias or bradycardia is present. Fifteen to 30 seconds are too short for accurate assessment. Sixty seconds is sufficient to assess heart rate and rhythm.

After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond?

a. Elevate the affected extremity.

b. Notify the practitioner of the observation.

c. Record data on the assessment flow record.

d. Apply warm compresses to the insertion site.

ANS: C

The pulse distal to the catheterization site may be weaker for the first few hours after

catheterization but should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are not indicated.

What statement best identifies the cause of heart failure (HF)?

a. Disease related to cardiac defects

b. Consequence of an underlying cardiac defect

c. Inherited disorder associated with a variety of defects

d. Result of diminished workload imposed on an abnormal myocardium

ANS: B

HF is the inability of the heart to pump an adequate amount of blood to the systemic circulation

at normal filling pressures to meet the bodys metabolic demands. HF is not a disease but rather a result of the inability of the heart to pump efficiently. HF is not inherited. HF occurs most frequently secondary to congenital heart defects in which structural abnormalities result in increased volume load or increased pressures on the ventricles.

A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?

a. 60 beats/min

b. 90 beats/min

c. 100 beats/min

d. 120 beats/min

ANS: B

If a 1-minute apical pulse is less than 90 beats/min for an infant or young child, the digoxin is

withheld. Sixty beats/min is the cut-off for holding the digoxin dose in an adult. One hundred to 120 beats/min is an acceptable pulse rate for the administration of digoxin.

A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action?

a. Assess for neurologic defects.

b. Prepare the family for imminent death.

c. Begin cardiopulmonary resuscitation.

d. Place the child in the kneechest position.

ANS: D

The first action is to place the infant in the knee-chest position. Blow-by oxygen may be

indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.

What blood flow pattern occurs in a ventricular septal defect?

a. Mixed blood flow

b. Increased pulmonary blood flow

c. Decreased pulmonary blood flow

d. Obstruction to blood flow from ventricles

ANS: B

The opening in the septal wall allows for blood to flow from the higher pressure left ventricle

into the lower pressure right ventricle. This left-to-right shunt creates increased pulmonary blood flow. The shunt is one way, from high pressure to lower pressure; oxygenated and unoxygenated blood do not mix. The outflow of blood from the ventricles is not affected by the septal defect.

The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication?

a. Hypoxemia

b. Right-to-left shunt of blood

c. Decreased workload on the left side of the heart

d. Pulmonary vascular congestion

ANS: D

In PDA, blood flows from the higher pressure aorta into the lower pressure pulmonary vein,

resulting in increased pulmonary blood flow. This creates pulmonary vascular congestion. Hypoxemia usually results from defects with mixed blood flow and decreased pulmonary blood flow. The shunt is from left to right in a PDA. The closure would stop this. There is increased workload on the left side of the heart with a PDA.

What cardiovascular defect results in obstruction to blood flow?

a. Aortic stenosis

b. Tricuspid atresia

c. Atrial septal defect

d. Transposition of the great arteries

ANS: A

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. Tricuspid atresia results in decreased pulmonary blood flow. The atrial septal defect results in increased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

What structural defects constitute tetralogy of Fallot?

a. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

c. Aortic stenosis, ventricular septal defect, overriding aorta, left ventricular hypertrophy

d. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

ANS: A

Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect,

overriding aorta, and right ventricular hypertrophy.

A parent of a 7-year-old girl with a repaired ventricular septal defect (VSD) calls the cardiology clinic and reports that the child is just not herself. Her appetite is decreased, she has had intermittent fevers around 38 C (100.4 F), and now her muscles and joints ache. Based on this information, how should the nurse advise the mother?

a. Immediately bring the child to the clinic for evaluation.

b. Come to the clinic next week on a scheduled appointment.

c. Treat the signs and symptoms with acetaminophen and fluids because it is most likely a viral illness.

d. Recognize that the child is trying to manipulate the parent by complaining of vague symptoms

ANS: A

These are the insidious symptoms of bacterial endocarditis. Because the child is in a high-risk

group for this disorder (VSD repair), immediate evaluation and treatment are indicated to prevent cardiac damage. With appropriate antibiotic therapy, bacterial endocarditis is successfully treated in approximately 80% of the cases. The childs complaints should not be dismissed. The low- grade fever is not a symptom that the child can fabricate.

What primary nursing intervention should be implemented to prevent bacterial endocarditis?

a. Counsel parents of high-risk children.

b. Institute measures to prevent dental procedures.

c. Encourage restricted mobility in susceptible children.

d. Observe children for complications, such as embolism and heart failure.

ANS: A

The objective of nursing care is to counsel the parents of high-risk children about the need for

both prophylactic antibiotics for dental procedures and maintaining excellent oral health. The childs dentist should be aware of the childs cardiac condition. Dental procedures should be done to maintain a high level of oral health. Restricted mobility in susceptible children is not indicated. Parents are taught to observe for unexplained fever, weight loss, or change in behavior.

What sign/symptom is a major clinical manifestation of rheumatic fever (RF)?

a. Fever

b. Polyarthritis

c. Osler nodes

d. Janeway spots

ANS: B

Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation. The

affected joints will change every 1 or 2 days. The large joints are primarily affected. Fever is considered a minor manifestation of RF. Osler nodes and Janeway spots are characteristic of bacterial endocarditis.

What action by the school nurse is important in the prevention of rheumatic fever (RF)?

a. Encourage routine cholesterol screenings.

b. Conduct routine blood pressure screenings.

c. Refer children with sore throats for throat cultures.

d. Recommend salicylates instead of acetaminophen for minor discomforts.

ANS: C

Nurses have a role in prevention, primarily in screening school-age children for sore throats

caused by group A streptococci. They can actively participate in throat culture screening or refer children with possible streptococcal sore throats for testing. Routine cholesterol screenings and blood pressure screenings do not facilitate the recognition and treatment of group A hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. What would be included in the intervention strategies?

A. The nurse would review the child's 24-hour diet recall.

B. The child should not be allowed to participate in sports.

C. Blood pressures should be measured daily.

D. Beta blocker education should be given to the parents.

ANS: A

Rationale: With a child in the 90th percentile for blood pressure, diet and physical activity should be the main focus. Blood pressures should be measured, but daily measurement is not necessary. Children are not routinely put on beta blockers, and the child should be allowed to participate in sports if monitored.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?

A. It will determine if the heart is enlarged.

B. It will determine disturbances in heart conduction.

C. It will show if blood is being shunted.

D. This image will clarify the structures within the heart.

ANS: A

Rationale: Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

The nurse is caring for a child diagnosed with rheumatic fever. When addressing the child's pain, the nurse should perform which intervention(s)? Select all that apply.

A. Carefully handle the child's knees, ankles, elbows and wrists when moving the

child.

B. Administer salicylates after meals or with milk.

C. Teach the child how to use a patient-controlled analgesia system.

D. Administer intravenous morphine as prescribed.

E. Prioritize nonpharmacologic interventions over pharmacologic interventions.

ANS: A, B

Rationale: Pain control and relief are the highest priorities for the child with rheumatic fever. Position the child to relieve joint pain. Large joints, including the knees, ankles, wrists, and elbows, are usually involved. Carefully handle the joints when moving the child to help minimize pain. Salicylates are administered in the form of aspirin to reduce fever but primarily to relieve joint inflammation and pain.They are also used as a heart protective. They are prescribed in high dosages. These are more commonly administered instead of opioids. Patient-controlled anesthesia is not typically used. Nonpharmacologic interventions can be used as an adjunct to pain medications.

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. What would the nurse expect to find? Select all that apply.

A. Tiring easily when eating

B. Shortness of breath when playing

C. Crackles on lung auscultation

D. Bradycardia

E. Hypertension

ANS: A, B, C

Rationale: Manifestations of heart failure include difficulty feeding or eating or becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.

The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli?

A. Pruritus

B. Roth spots

C. Delayed capillary refill

D. Erythema marginatum

ANS: B

Rationale: Roth spots are splinter hemorrhages with pale centers on the sclerae, palate, buccal mucosa, chest, fingers, or toes, and are signs of extracardiac emboli. Delayed capillary refill time does not point to extracardiac emboli. Wheezing and pruritus are indicative of a hypersensitivity reaction. Erythema marginatum is a classic rash associated with acute rheumatic fever.

When assessing a infant born at 32 weeks' gestation, which finding would lead the nurse to suspect to suspect that the newborn has a patent ductus arteriosus (PDA)?

A. Weak, thready pulse

B. Decreased pulse rate

C. High diastolic arterial pressure

D. Continuous murmur on auscultation

ANS: D

Rationale: Presence of a continuous murmur on auscultation of the heart is indicative of patent ductus arteriosus (PDA) in preterm infants. Preterm infants are at an increased risk of developing PDA. Other assessment findings that indicate PDA include bounding pulse, increased pulse rate and low diastolic arterial pressure.

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

ANS: A, C

Rationale: 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 nurse receives the shift report of multiple pediatric clients. Which pediatric client will the nurse see first?

A. an infant whose parents report difficulty feeding with a temperature of 100.1°F (38°C)

B. a toddler with tetralogy of Fallot squatting quietly in the corner of the room

C. a child with history of hypertension and a current blood pressure of 130/90 mm Hg

D. an adolescent with coarctation of the aorta with reports of coughing and coryza

ANS: B

Rationale: The first child the nurse will see is the child showing signs and symptoms of decreased pulmonary blood flow and possible hypercyanotic (tet) spell, which includes a toddler with tetralogy of Fallot squatting. Squatting increases systemic vascular resistance and forces blood to flow through the narrow pulmonary valve to improve oxygenation. An infant with difficult feeding and an elevated temperature may have an infection but could be seen after addressing a potential respiratory/circulatory issue. The child with history of hypertension who has an elevated blood pressure can be seen later because this is an expected finding and not life-threatening. The adolescent with coarctation of the aorta being seen for coughing and coryza without any other signs of distress can also be seen later.

A 4-year-old child is scheduled for an echocardiogram. The nurse is explaining this procedure to the child's parents. Which information would the nurse likely include? Select all that apply.

A. "This test uses sound waves to check the heart structures."

B. "This test should not cause your child any pain."

C. "This test exposes your child to radiation so we need to be careful."

D. "This test checks the electrical conduction of your child's heart."

"This test will require us to give your child a small amount of anesthesia."

ANS: A, B

Rationale: An echocardiogram is a noninvasive ultrasound procedure used to assess heart wall thickness, size of heart chambers, motion of valves and septa, and relationship of great vessels to other cardiac structures. It should not cause any pain for the child. No sedation or anesthesia is needed for an echocardiogram. However, the child needs to lie still throughout the test. A chest x-ray or radiograph would expose the child to radiation. An electrocardiogram records the electrical activity of the heart.