Chapter 29: The Child with Cardiovascular Dysfunction
MULTIPLE CHOICE
4. After returning from cardiac catheterization, the nurse monitors the child’s 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.
5. Afterreturning 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.
6. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells
the nurse that her bandage is “too wet.” The nurse finds the bandage and bed soaked with blood.
What nursing action is most appropriate to institute initially?
a. Notify the physician.
b
. Place the child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d
. Apply direct pressure above the catheterization site.
ANS: D
When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the
percutaneous skin site to localize pressure on the vessel puncture. The physician can be notified,
and a new bandage with more pressure can be applied after pressure is applied. The nurse can
have someone else notify the physician while the pressure is being maintained. Trendelenburg
positioning would not be a helpful intervention. It would increase the drainage from the lower
extremities.
8. The
nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep.
What nursing intervention is most appropriate at this time?
a. Administer oxygen.
b
. Record data on the nurses’ notes.
c. Report data to the practitioner.
d
. Place the child in the high Fowler position.
ANS: C
One of the earliest signs of HF is tachycardia (sleeping heart rate >160 beats/min) as a direct
result of sympathetic stimulation. The practitioner needs to be notified for evaluation of possible
HF. Although oxygen or a semiupright position may be indicated, the first action is to report the
data to the practitioner.
10. A2-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.
11. What clinical manifestation is a common sign of digoxin toxicity?
a. Seizures
b
. Vomiting
c. Bradypnea
d
. Tachycardia
ANS: B
Vomiting is a common sign of digoxin toxicity and is often unrelated to feedings. Seizures are
not associated with digoxin toxicity. The child will have a slower (not faster) heart rate but not a
slower respiratory rate.
15. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The
nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an
important objective to decrease this risk?
a. Minimize seizures.
b
. Prevent dehydration.
c. Promote cardiac output.
d
. Reduce energy expenditure.
ANS: B
In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in
hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting
cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular
accidents.
16. A 3-month-old infant has a hypercyanotic spell. What should be the nurse’s first action?
a. Assess for neurologic defects.
b
. Prepare the family for imminent death.
c. Begin cardiopulmonary resuscitation.
d
. Place the child in the knee–chest 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.
17. A cardiac defect that allows blood to shunt from the (high pressure) left side of the heart to
the (lower pressure) right side can result in which condition?
a. Cyanosis
b
. Heart failure
c. Decreased pulmonary blood flow
d
. Bounding pulses in upper extremities
ANS: B
As blood is shunted into the right side of the heart, there is increased pulmonary blood flow and
the child is at high risk for heart failure. Cyanosis usually occurs in defects with decreased
pulmonary blood flow. Bounding upper extremity pulses are a manifestation of coarctation of the
aorta.
18. 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.
19. Thephysician 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.
20. 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.
21. What structural defects constitute tetralogy of Fallot?
Pulmonary stenosis, ventricular septal defect, overriding aorta, right
a. ventricular hypertrophy
b Aortic stenosis, ventricular septal defect, overriding aorta, right
. ventricular hypertrophy
Aortic stenosis, ventricular septal defect, overriding aorta, left
c. 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.
22. The parents of a 3-year-old child with congenital heart disease are afraid to let their child play
with other children because of possible overexertion. How should the nurse reply to this
concern?
a. The parents should meet all the child’s needs.
b
. The child needs opportunities to play with peers.
c. Constant parental supervision is needed to avoid overexertion.
d
. The child needs to understand that peers’ activities are too strenuous.
ANS: B
The child needs opportunities for social development. Children are able to regulate and limit
their activities based on their energy level. Parents must be encouraged to seek appropriate social
activities for the child, especially before kindergarten. The child needs to have activities that
foster independence.
27. 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.
Treat the signs and symptoms with acetaminophen and fluids because
c. 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 child’s complaints should not be dismissed. The low-
grade fever is not a symptom that the child can fabricate.
28. 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
child’s dentist should be aware of the child’s 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.
29. 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.
30. 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.
31. When caring for the child with Kawasaki disease, what should the nurse know to provide safe
and effective care?
a. Aspirin is contraindicated.
b
. The principal area of involvement is the joints.
c. The child’s fever is usually responsive to antibiotics within 48 hours.
d Therapeutic management includes administration of gamma globulin
. and salicylates.
ANS: D
High-dose intravenous gamma globulin and salicylate therapy are indicated to reduce the
incidence of coronary artery abnormalities when given within the first 10 days of the illness.
Aspirin is part of the therapy. Mucous membranes, conjunctiva, changes in the extremities, and
cardiac involvement are seen. The fever of Kawasaki disease is unresponsive to antibiotics. It is
responsive to anti-inflammatory doses of aspirin and antipyretics.
32. Nursing care of the child with Kawasaki disease is challenging because of which occurrence?
a. The child’s irritability
b
. Predictable disease course
c. Complex antibiotic therapy
d
. The child’s ongoing requests for food
ANS: A
Patient irritability is a hallmark of Kawasaki disease and is the most challenging problem. A
quiet environment is necessary to promote rest. The diagnosis is often difficult to make, and the
course of the disease can be unpredictable. Intravenous gamma globulin and salicylates are the
therapy of choice, not antibiotics. The child often is reluctant to eat. Soft foods and fluids should
be offered to prevent dehydration.
38. Achild with heart failure is on Lanoxin (digoxin). The laboratory value a nurse must closely
monitor is which?
a. Serum sodium
b
. Serum potassium
c. Serum glucose
d
. Serum chloride
ANS: B
A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin
toxicity. Increased serum potassium levels diminish digoxin’s effect. Therefore, serum potassium
levels (normal range, 3.5–5.5 mmol/L) must be carefully monitored.
39. An infant has tetralogy of Fallot. In reviewing the record, what laboratory result should the
nurse expect to be documented?
a. Leukopenia
b
. Polycythemia
c. Anemia
d
. Increased platelet level
ANS: B
Persistent hypoxemia that occurs with tetralogy of Fallot stimulates erythropoiesis, which results
in polycythemia, an increased number of red blood cells.
40. What child has a cyanotic congenital heart defect?
a. An infant with patent ductus arteriosus
b
. A 1-year-old infant with atrial septal defect
c. A 2-month-old infant with tetralogy of Fallot
d
. A 6-month-old infant with repaired ventricular septal defect
ANS: C
Tetralogy of Fallot is a cyanotic congenital heart defect. Patent ductus arteriosus, atrial septal
defect, and ventricular septal defect are acyanotic congenital heart defects.
41. The nurse is teaching parents about administering digoxin (Lanoxin). What instructions
should the nurse tell the parents?
a. If the child vomits, give another dose.
b
. Give the medication at regular intervals.
c. If a dose is missed, give a give an extra dose.
d
. Give the medication mixed with the child’s formula.
ANS: B
The family should be taught to administer digoxin at regular intervals. If a dose is missed, an
extra dose should not be given; the same schedule should be maintained. If the child vomits, do
not give a second dose. The drug should not be mixed with foods or other fluids because refusal
to consume these would result in inaccurate intake of the drug.
43. Thehealth care provider suggests surgery be performed for ventricular septal defect to
prevent what complication?
a. Pulmonary hypertension
b
. Right-to-left shunt of blood
c. Pulmonary embolism
d
. Left ventricular hypertrophy
ANS: A
Congenital heart defects with a large left-to-right shunt (e.g., in ventricular septal defect, patent
ductus arteriosus, or complete AV canal), which cause increased pulmonary blood flow, may
result in pulmonary hypertension. If these defects are not repaired early, the high pulmonary flow
will cause changes in the pulmonary artery vessels, and the vessels will lose their elasticity. The
blood does not shunt right to left, a pulmonary embolism is not a complication of ventricular
septal defect, and the left ventricle does not hypertrophy.
44. A 1-year-old has been admitted for complete repair of a tetralogy of Fallot. What assessment
finding should the nurse expect to be documented?
a. Weight gain
b
. Pale skin color
c. Increasing cyanosis
d
. Decrease in hemoglobin and hematocrit
ANS: C
Elective repair of tetralogy of Fallot is usually performed in the first year of life. Indications for
repair include increasing cyanosis and the development of hypercyanotic spells. The child would
not have a weight gain, pale skin color, or decrease in hemoglobin and hematocrit.
45. A 6-month-old infant presents to the clinic with failure to thrive, a history of frequent
respiratory infections, and increasing exhaustion during feedings. On physical examination, a
systolic murmur is detected, no central cyanosis, and chest radiography reveals cardiomegaly.
An echocardiogram is done that shows left-to-right shunting. This assessment data is
characteristic of what?
a. Tetralogy of Fallot
b
. Coarctation of the aorta
c. Pulmonary stenosis
d
. Ventricular septal defect
ANS: D
Heart failure is common with ventricular septal defect that causes failure to thrive, respiratory
infections, and an increase in exhaustion during feedings. There is a characteristic murmur. The
other defects do not have left-to-right shunting.
46. An infant is diagnosed with transposition of the great vessels. Prostaglandin E1 is given
intravenously. The parents ask how long the child will remain on the prostaglandin E1. What is
the appropriate response by the nurse?
Prostaglandin E1 will be given intermittently until corrective surgery
a. is performed.
b Prostaglandin E1 will be given continuously until corrective surgery is
. performed.
Prostaglandin E1 will be given continuously throughout the
c. preoperative and postoperative periods until the child is stable.
d Prostaglandin E1 will be given intermittently throughout the
. preoperative and postoperative periods until the child is stable.
ANS: B
To provide intracardiac mixing for a child with transposition of the great arteries, intravenous
prostaglandin E1 is administered continuously to keep the ductus arteriosus open to temporarily
increase blood mixing and provide an oxygen saturation of 75% or to maintain cardiac output
until surgery. It is discontinued after surgery.
47. What medication used to treat heart failure (HF) is a diuretic?
a. Captopril (Capten)
b
. Digoxin (Lanoxin)
c. Hydrochlorothiazide (Diuril)
d Carvedilol (Coreg)
.
ANS: C
Hydrochlorothiazide is a diuretic. Captopril is an ACE inhibitor, digoxin is a digital glycoside,
and carvedilol is a beta-blocker.
48. Thenurse is preparing to give digoxin (Lanoxin) to a 9-month-old infant. The nurse checks
the dose and draws up 4 ml of the drug. The most appropriate nursing action is which?
a. Mix the dose with juice to disguise its taste.
b
. Do not give the dose; suspect a dosage error.
Check the heart rate; administer digoxin if the rate is greater than 100
c. beats/min.
d Check the heart rate; administer digoxin if the rate is greater than 80
. beats/min.
ANS: B
Infants rarely receive more than 1 ml (50 mcg, or 0.05 mg) of digoxin in one dose; a higher dose
is an immediate warning of a dosage error. To ensure safety, compare the calculation with that of
another staff member before giving digoxin.
50. Bacterial infective endocarditis (IE) should be treated with which protocol?
a. Oral antibiotics for 6 months
b
. Oral antibiotics (penicillin) for 10 full days
c. IV antibiotics, diuretics, and digoxin
d
. IV antibiotics (penicillin type) for 2 to 8 weeks
ANS: D
Treatment for IE includes the administration of high-dose antibiotics given intravenously for 2 to
8 weeks to completely eradicate the infecting microorganism.
51. A child is recovering from Kawasaki disease (KD). The child should be monitored for which?
a. Anemia
b
. Electrocardiograph (ECG) changes
c. Elevated white blood cell count
d
. Decreased platelets
ANS: B
The most serious complication of KD is the development of coronary artery aneurysms and the
potential for myocardial infarction in children with aneurysm formation. The nurse should
monitor any ECG changes.
52. The test that provides the most reliable evidence of recent streptococcal infection is which?
a. Throat culture
b
. Mantoux test
c. Antistreptolysin O test
d
. Elevation of liver enzymes
ANS: C
Antistreptolysin O (ASLO) titers measure the concentration of antibodies formed in the blood
against this product. Normally, the titers begin to rise about 7 days after onset of the infection
and reach maximum levels in 4 to 6 weeks. Therefore, a rising titer demonstrated by at least two
ASLO tests is the most reliable evidence of recent streptococcal infection.
MULTIPLE RESPONSE
1. Thenurse is caring for a child with Kawasaki disease in the acute phase. What clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Osler nodes
b
. Cervical lymphadenopathy
c. Strawberry tongue
d
. Chorea
e. Erythematous palms
f. Polyarthritis
ANS: B, C, E
Clinical manifestations of Kawasaki disease in the acute phase include cervical
lymphadenopathy, a strawberry tongue, and erythematous palms. Osler nodes are a clinical
manifestation of endocarditis. Chorea and polyarthritis are seen in rheumatic fever.
6. An adolescent is being placed on a beta-blocker. What should the nurse inform the adolescent
with regard to this medication? (Select all that apply.)
a. Medication may cause fatigue.
b
. Side effects may include impotence.
c. Side effects may include bradycardia.
d
. Take the medication 1 hour before meals.
e. Side effects may include peripheral edema.
ANS: A, B, C
The adolescent should be instructed that the medication may cause fatigue, impotence, and
bradycardia. The medications should be taken with meals and side effects do not include
peripheral edema.
7. Anadolescent is being placed on a calcium channel blocker. What should the nurse inform the
adolescent with regard to this medication? (Select all that apply.)
a. The medication may cause fatigue.
b
. The medication may increase heart rate.
c. The medication may cause constipation.
d
. The medication may cause cold extremities.
e. The medication may cause peripheral edema.
ANS: B, C, E
Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral
edema. Beta-blockers can cause fatigue and cold extremities, but calcium channel blockers do
not cause these potential side effects.
