NCLEX Pediatric: Cardiovascular Questions
Pediatric: Cardiovascular NCLEX Practice Questions
Question 1.
The nurse is talking with the parents of a 6-week-old infant regarding their child’s cardiac catheterization for repair of a ventricular septal defect (VSD) and home care. Which of the following instructions does the nurse include in the discharge teaching?
(a) “Restrict the child’s physical activity for 2 weeks following the procedure.”
(b) “The incision cannot be submerged in water, so give the child a sponge bath daily until the stitches are removed.”
(c) “Prophylactic antibiotics must be used before future dental procedures.”
(d) “Keep the pressure dressing on the site until the healthcare provider evaluates it.”
Answer:
(c) “Prophylactic antibiotics must be used before future dental procedures.”
Explanation:
A Ventricular Septal Defect (VSD) occurs when the hole between the ventricles of the heart does not close before the fetus is born. This allows blood between the ventricles to mix, which decreases oxygenation of the blood. A VSD repair closes the hole in the septum between the ventricles. 'The surgeon sews the hole closed or patches the hole with the baby’s own tissue or a synthetic patch. Patients with heart defects must have prophylactic antibiotics before any future dental procedures to reduce the risk of infection.
Rationale:
(a) is incorrect because activities do not need to be restricted after a VSD repair.
(b) is incorrect because stitches are not used after cardiac catheterization.
(d) is incorrect because a pressure dressing is not used after discharge for cardiac catheterization. The parents will be taught how to change the clean dressing at home and inspect the puncture site for signs of infection.
Question 2.
A 2-year-old girl diagnosed with Tetralogy of Fallot is having blood drawn for routine tests when she becomes upset, turns blue, and her breathing rate increases to 46 breaths per minute. Which intervention does the nurse perform first?
(a) Contact the healthcare provider for a sedation order
(b) Assess the child’s heart rate and rhythm for irregularity
(c) Reassure the child that mild pain is expected during the blood draw
(d) Position the child with knees to chest
Answer:
(d) Position the child with knees to chest
Explanation:
Tetralogy of Fallot is a congenital heart defect that includes ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle, and an overriding aorta. The knees-to-chest position will reduce venous return, thereby reducing shunting of blood through the defect in the septum, which increases oxygen in the systemic blood circulation and decreases dyspnea and tachypnea.
Rationale:
(a) is incorrect because sedation is not needed unless repositioning is ineffective.
(b) is incorrect because further assessment should be performed after repositioning the child. The knee to chest position will most immediately help with the child’s breathing.
(c) is incorrect because reassuring the child is an appropriate psychosocial intervention, but this will not relieve the hypoxia. The nurse must prioritize actual physical needs over psychosocial needs.
Question 3.
A 6-year-old is admitted to the pediatric emergency room with rheumatic fever. When assessing the child, which of the following signs does the nurse identify as an initial sign of infective endocarditis?
(a) Anterior chest wall pain
(b) Irregular heart rhythm
(c) Heart murmur
(d) Hypotension
Answer:
(c) Heart murmur
Explanation:
Rheumatic fever typically develops 2 to 4 weeks after a strep throat infection. Infective endocarditis occurs when the bacteria enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel, causing infection and inflammation of the endocardium. With endocarditis, heart murmurs can present in approximately 75 percent of patients in the first week. Other symptoms include fever and chills, aching joints, night sweats, and fatigue.
Rationale:
(a) is incorrect because anterior chest wall pain does not usually occur with infective endocarditis. This type of pain is commonly a sign of costochondritis, an inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall.
(b) is incorrect because the heart rhythm with endocarditis is commonly tachycardia but is not irregular.
(d) is incorrect because hypotension does not usually occur with endocarditis.
Question 4.
A 12-year-old boy with a history of asthma visits the school nurse reporting chest pain. After the nurse confirms that the boy has not had complications with his asthma in several years, what is the next action the nurse should perform?
(a) Obtain peak flow reading
(b) Instruct the boy to lay down for 10 minutes
(c) Call the child’s parents for more information
(d) Administer two puffs of a short-acting bronchodilator
Answer:
(a) Obtain peak flow reading
Explanation:
Asthma is chronic inflammation and obstruction in the lungs with symptoms including chest tightness, wheezing, coughing, and shortness of breath. More assessment needs to be done before intervening with this child. A peak flow reading and vital signs should be obtained before notifying the parents or healthcare provider.
Rationale:
(b) is incorrect because the priority is assessing the airway. Having the boy lie down may make it more difficult for him to breathe.
(c) is incorrect because immediate airway assessment needs to be performed before notifying the parents.
(d) is incorrect because assessment needs to be performed before administering a short-acting bronchodilator. The nurse must obtain a baseline measurement using the peak flow meter to determine if the bronchodilator is necessary.
Question 5.
A 7-year-old girl with a history of asthma tells the school nurse she is interested in joining one of the school’s sports teams. Which of the following sports does the nurse suggest for her?
(a) Soccer
(b) Track and field
(c) Swimming
(d) Ice skating
Answer:
(c) Swimming
Explanation:
Asthma is chronic inflammation and obstruction in the lungs with symptoms including chest tightness, wheezing, coughing, and shortness of breath. Swimming is a low-impact sport that promotes ventilation and perfusion while enhancing skeletal muscle mass. Any sport that requires frequent stop-and-start exertion can cause asthma exacerbation. Sports suggested for asthmatic children include swimming, baseball or softball, golf, martial arts, fencing, and volleyball.
Rationale:
(a) is incorrect because soccer is a vigorous activity which takes place over a long period of time and can cause asthma exacerbation.
(b) is incorrect because track and field often involves a level of intensity that can be hard on the respiratory system and cause asthma exacerbation.
(d) is incorrect because cold-weather activities, such as ice skating, ice hockey, snow skiing, or snowboarding, can be hard on asthma sufferers. They're taxing on the lungs and on the body.
Question 6.
The nurse is teaching the parents of a 6-year-old with cystic fibrosis (CF) , regarding dietary choices. Which of the following is not an appropriate
food choice for the child?
(a) Roasted pork tenderloin
(b) Fried chicken
(c) Skim chocolate milkshake
(d) Egg omelet
Answer:
(b) Fried chicken
Explanation:
Cystic fibrosis (CF) affects production of mucous and sweat, causing dysfunction in the lungs and digestive system. CF children have a deficiency of pancreatic enzymes, disrupting the body’s ability to digest and absorb fat, leading to weight loss. Patients with cystic fibrosis require a high-nutrient, high-protein, and low-fat diet with pancreatic enzyme replacement.
Rationale:
(a) is incorrect because roasted pork tenderloin is nutrient and protein dense.
(c) is incorrect because a skim milkshake is low in fat and offers a good source of calories.
(d) is incorrect because an egg omelet is nutrient dense.
Question 7.
The nurse is caring for infants in the intensive care unit (ICU). Which of the following is at the greatest risk for sudden infant death syndrome (SIDS)?
(a) 3-month-old infant who is laid to sleep on his back
(b) 6-month-old infant who has had pneumonia twice
(c) First born infant of a 40-year-old mother
(d) 2 month old with frequent 5-second apnea episodes
Answer:
(d) 2 month old with frequent 5-second apnea episodes
Explanation:
Sudden infant death syndrome (SIDS) is unexplained and sudden death of a child under the age of l year. Infants between the ages of 2 and 4 months have the highest risk of SIDS, and apnea episodes greater than 20 seconds indicate a higher risk of SIDS. Other factors that increase the risk for SIDS include when the baby gets too hot during sleep, shares a bed with others, sleeps on soft surfaces (such as an adult mattress), or sleeps under soft or loose bedding.
Rationale:
(a) is incorrect because lying the baby on his back to sleep is safe. When a baby sleeps on his stomach, the risk for SIDS increases.
(b) is incorrect because respiratory illness does not increase risk of SIDS.
(c) is incorrect because older maternal age does not increase risk of SIDS.
Question 8.
The nurse finds a 4-year-old boy unresponsive and not breathing in the daycare center. After instructing another individual to call 911, which of the following interventions does the nurse perform next?
(a) Give a precordial thump
(b) Give breaths with bag-valve-mask (BVM) at a rate of 16 bpm
(c) Open and clear the airway
(d) Start chest compressions at a rate of 100 per minute
Answer:
(c) Open and clear the airway
Explanation:
Clearing the airway is always the first intervention in cardiopulmonary resuscitation, especially when the collapse was not witnessed. In children, apnea and unconsciousness are usually due to pathophysiology of the respiratory system. Time is very important when dealing with an unconscious child who is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to ,6 minutes later.
Rationale:
(a) is incorrect because a precordial thump is generally not indicated for pediatrics. This medical procedure is used in the treatment of ventricular fibrillation or pulseless ventricular tachycardia in those with witnessed, monitored onset of one of the "shockable" cardiac rhythms if a defibrillator is not immediately available. It should not be used in those with unwitnessed or out-of-hospital cardiac arrest.
(b) is incorrect because the airway should be cleared before giving breaths.
(d) is incorrect because in incidences where the nurse did not witness the collapse, the airway should be cleared, and rescue breaths should be given before compressions are started. (If the nurse witnessed the child suddenly collapse, rescue breaths should be skipped, and compressions should be started.)
Question 9.
The nurse in the pediatric cardiac unit is caring for a 2-year-old scheduled for heart surgery. Which of the following interventions does the nurse use to best decrease anxiety for the child’s parents?
(a) Reassure the parents of the surgeon’s success rate
(b) Offer to obtain an order for an anxiolytic for the parents
(c) Teach the parents and the child about the surgery one month before the surgery
(d) Explain the steps involved before and after the procedure
Answer:
(d) Explain the steps involved before and after the procedure
Explanation:
Heart surgery in pediatrics is performed to correct congenital heart defects. It is appropriate for the nurse to give the parents something tangible to focus on by explaining what to expect. This is often an effective way to reduce the parents’ anxiety about the upcoming procedure and enable them to cooperate in the plan of care.
Rationale:
(a) is incorrect because the nurse needs to hear the concerns of the parents instead of dismissing them by focusing on the surgeon.
(b) is incorrect because obtaining anxiolytics for the parents is inappropriate. The parents are not the patient.
(c) is incorrect because preoperative teaching should be performed within a week of the surgery, not one month.
Question 10.
The nurse in the pediatric cardiac unit is caring for a 3-year-old child with Kawasaki disease. The nurse knows which of the following medications is typically administered to children with Kawasaki disease?
(a) Acetaminophen
(b) Amoxicillin
(c) Aspirin
(d) Ibuprofen
Answer:
(c) Aspirin
Explanation:
Kawasaki disease is an autoimmune disease often seen in children under the age of 5 years. The disease causes vasculitis that affects small- and medium-sized blood vessels and lymph nodes and may progress to affect the patient’s coronary arteries. Aspirin is administered daily to children with Kawasaki disease for anti-inflammatory purposes as well as to control fever. Once fever subsides, aspirin is continued as an antiplatelet. Immunoglobulins are also administered in the initial treatment for Kawasaki.
Rationale:
(a) is incorrect because acetaminophen does not have blood-thinning properties and is often ineffective in reducing the fever in a child with Kawasaki.
(b) is incorrect because amoxicillin is not effective for treating Kawasaki. Amoxicillin is an antibiotic which can be used to treat a bacterial infection. (Kawasaki is an autoimmune disease, which can be triggered by infection.)
(d) is incorrect because the blood-thinning properties of ibuprofen are not as effective as aspirin.
Question 11.
The nurse in the neonatal intensive care unit (NICU) is assessing a 1- week-old male infant. When the brachial, radial, and femoral pulses are palpated, a difference in amplitude is noted between the bilateral femoral and radial pulses. The nurse knows this finding suggests which of the following?
(a) Patent ductus arteriosus
(b) Coarctation of the aorta
(c) Increased cardiac output
(d) Fluid volume overload
Answer:
(b) Coarctation of the aorta
Explanation:
Coarctation of the aorta is narrowing of the aorta below the left subclavian artery. This requires the left ventricle to generate a much higher pressure than normal in order to force enough blood through the aorta to deliver blood to the lower part of the body. If the left ventricle is not strong enough to push blood through the narrowed aorta, the result may be decreased blood flow to the lower half of the body, which can cause a difference in amplitude between the femoral and radial pulses (in which the radial pulse is generally stronger than the femoral pulse bilaterally). Coarctation is twice as common in boys than in girls.\
Rationale:
(a) is incorrect because patent ductus arteriosus (PDA) is manifested by bounding pulse due to left-to-right shunting of the blood in the heart. Irregular transmission of blood from the aorta to the pulmonary artery occurs. Other symptoms include tachycardia, dyspnea, and poor growth. PDA has a high occurrence in premature newborns.
(c) is incorrect because increased cardiac output is manifested by a strong and bounding pulse, not a difference between femoral and radial pulses.
(d) is incorrect because fluid volume overload in a newborn would be characterized by weight gain, edema, a bounding pulse, shortness of breath, and pulmonary congestion.
Question 12.
The nurse in the pediatric cardiac unit is caring for a 3-year-old boy diagnosed with Tetralogy of Fallot. When the nurse assesses the boy, the nurse expects fatigue and poor activity tolerance, which are caused by which of the following?
(a) Poor muscle tone
(b) Inadequate oxygenation of tissues
(c) Restriction of blood flow leaving the heart
(d) Inadequate intake of food
Answer:
(b) Inadequate oxygenation of tissues
Explanation:
Tetralogy of Fallot is a cyanotic congenital heart defect which includes four defects: ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle, and an overriding aorta. The condition causes left- to-right shunting of the blood in the heart which causes inadequate oxygenation of tissues.
A is incorrect because poor muscle tone is a result of Tetralogy of Fallot, pot a cause. Other findings of Tetralogy of Fallot include clubbing of the fingers, poor sucking reflex, lethargy, and cyanosis.
Rationale:
(c) is incorrect because restriction of blood flow leaving the heart is caused by aortic stenosis, which is a narrowing of the aortic valve that decreases cardiac output.
(d) is incorrect because Tetralogy of Fallot causes a poor sucking reflex and lethargy, which results in inadequate food intake. However, the cause is poor tissue oxygenation due to mixed blood between the right and left sides of the heart.
Question 13.
The nursing student in the pediatric cardiac unit is learning about congenital heart defects. The student learns that which congenital heart defect causes pediatric cyanosis?
(a) Atrial septal defect
(b) Coarctation of the aorta
(c) Ventricular septal defect
(d) Transposition of the great vessels
Answer:
(d) Transposition of the great vessels
Explanation:
Transposition of the great vessels means the pulmonary artery is connected to the left ventricle and the aorta is connected to the right ventricle, causing blood to reach the tissues before being oxygenated in the lungs. This leads to cyanosis in the pediatric patient.
Rationale:
(a) is incorrect because an atrial septal defect (abnormal opening between the right and left atria of the heart) is an acyanotic congenital malformation.
(b) is incorrect because coarctation of the aorta narrows the aorta and decreases oxygenated blood circulation to the body. Coarctation is an acyanotic congenital malformation.
(c) is incorrect because ventricular septal defect (abnormal opening between the right and left ventricles of the heart) is an acyanotic congenital malformation.
Question 14.
The nurse in the pediatric intensive care unit (PICU) is caring for a 6- week-old female patient diagnosed with Tetralogy of Fallot (TOF). When assessing the child, the nurse expects to find which common physiologic adaptation?
(a) Clubbing of the fingers
(b) Slow, irregular respirations
(c) Subcutaneous hemorrhage
(d) Decreased red blood cell count
Answer:
(a) Clubbing of the fingers
Explanation:
TOF is a congenital heart defect that includes ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle, and an overriding aorta. Symptoms include bluish color to the skin and clubbing of the fingers due to hypoxia causing poor circulation to the periphery. When the infant cries or has a bowel movement, they may experience a “tet” spell in which the child turns very blue in color, has difficulty breathing, becomes limp, and may even lose consciousness. Other symptoms may include a heart murmur and fatigue when feeding.
Rationale:
(b) is incorrect because TOF is characterized by shortness of breath, not slow and irregular respirations.
(c) is incorrect because subcutaneous hemorrhage is not commonly seen 'With TOF. Subcutaneous hemorrhage in infants is usually the result of birth trauma or certain rare viruses.
(d) is incorrect because TOF does not cause an abnormally low number of red blood cells. A compensatory mechanism for the cyanotic congenital heart defects is polycythemia, or increased hemoglobin and/or red blood cells.
Question 15.
The nurse in the pediatric cardiac unit is caring for a 5-year-old boy diagnosed with a ventricular septal defect (VSD) who is scheduled for a cardiac catheterization. The nurse tells the boy’s parents the purpose of the cardiac catheterization is:
(a) To identity the specific location of the VSD
(b) To determine the degree of cardiomegaly
(c) To confirm the presence of a pansystolic murmur
(d) To establish the presence of ventricular hypertrophy
Answer:
(a) To identity the specific location of the VSD
Explanation:
Ventricular septal defect (VSD) is an acyanotic congenital heart defect. This occurs when the hole between the ventricles of the heart does not close before the fetus is born, allowing blood between the ventricles to mix, which decreases oxygenation of the blood pumped out of the heart. The size can vary from as small as a pin-hole to the child having no septum at all. The purpose of cardiac catheterization with VSD is to determine the specific location and size of the defect and to assess pressures in the pulmonary system.
Rationale:
(b) is incorrect because cardiomegaly is determined by echocardiogram, not catheterization.
(c) is incorrect because a pansystolic murmur (also known as a harsh holosystolic murmur, heard at the left lower sternal border) can generally be detected by cardiac auscultation with a stethoscope and does not require catheterization to be detected. This is the classic murmur heard in patients with VSD.
(d) is incorrect because although ventricular hypertrophy is common with VSD, it is not determined by catheterization.
Question 16.
The nurse in the pediatric clinic is assessing a 5-year-old girl with a congenital cardiac defect. When the mother asks why her daughter squats after exertion, the nurse tells the mother this position does which of the following?
(a) Reduces muscle aches
(b) Increases cardiac efficiency
(c) Relieves anxiety associated with high blood pressure
(d) Decreases blood volume in the extremities
Answer:
(b) Increases cardiac efficiency
Explanation:
Congenital heart defects are abnormalities of the heart that develop in utero or failure of normal in-utero shunts to close before or during birth. Squatting causes blood to pool in the lower extremities due to flexion of the hips and knees. This causes a decrease in blood volume returning to the heart, which allows the heart to beat more effectively.
Rationale:
(a) is incorrect because the squatting position after physical exertion is not due to aching muscles, it is a result of dyspnea.
(c) is incorrect because squatting does not directly relieve anxiety, and children with congenital heart defects do not squat because of abnormal blood pressure; they assume this position because of breathlessness after pxertion.
(d) is incorrect because the squatting position retains blood volume in the extremities which improves efficiency of the cardiac pump.
Question 17.
An infant diagnosed with Tetralogy of Fallot becomes cyanotic and dyspneic following an episode of crying. For relief of the cyanosis and dyspnea, the nurse places the infant in which position?
(a) Orthopneic position
(b) Knee-chest position
(c) Lateral Sims’ position
(d) Semi-fowler’s position
Answer:
(b) Knee-chest position
Explanation:
Tetralogy of Fallot (TOF) is a congenital heart defect that includes ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle, and an overriding aorta. Flexing the knees and hips will decrease venous blood return to the heart from the extremities, which will decrease the workload of the heart.
Rationale:
(a) is incorrect because the orthopneic position is a position in which the patient assumes an upright or semi-vertical position by using pillows to support the head and chest or sits upright in a chair. This is used for people who have difficulty breathing when lying down but is not associated with relief of dyspnea from TOF.
(c) is incorrect because the lateral Sims’ position is generally used for rectal treatment, enema, or examination. The patient lies on the left side with the left hip and lower extremity straight and right hip and knee bent.
(d) is incorrect because a Semi-fowler’s position (laying supine with the head of bed elevated at 30 to 45 degrees) does not help relieve the dyspnea associated with TOF after a crying episode (or physical exertion).
Question 18.
The nurse in the neonatal cardiac unit is caring for a 2-week-old patient diagnosed with congenital heart disease and heart failure. The nurse knows the most appropriate action is which of the following?
(a) Positioning the infant prone after feeding
(b) Encouraging PO water intake
(c) Offering small, frequent feedings
(d) Measuring head circumference
Answer:
(c) Offering small, frequent feedings
Explanation:
Congenital heart defects are abnormalities of the heart that develop in utero or failure of normal in utero shunts to close before or during birth. Congenital heart disease with heart failure causes extreme fatigue with sucking in an infant, so smaller, frequent feedings and adequate rest periods should be provided to improve nutritional intake.
Rationale:
(a) is incorrect because positioning a child with congenital heart disease and heart failure prone after feeding is unsafe. The baby should be placed on its right side after feeding to prevent the risk for aspiration.
(b) is incorrect because an infant at the age of 2 weeks does not need PO water.
(d) is incorrect because assessment of head circumference is not a specific priority assessment of a newborn with congenital heart disease and heart failure.
Question 19.
An 8-year-old female patient is admitted to the pediatric cardiac unit ,with myocarditis and tachycardia. The healthcare provider has ordered furosemide to be administered every 12 hours. Which of the following lab values does the nurse closely monitor?
(a) Calcium
(b) Glucose
(c) Potassium
(d) Sodium
Answer:
(c) Potassium
Explanation:
Myocarditis is inflammation of the heart muscle, and tachycardia is increased heart rate for patient age. Furosemide is a loop diuretic that rids the body of excess fluid but also wastes potassium. The potassium level should be monitored frequently for the duration of the time that the child is receiving furosemide. If symptoms of hypokalemia are present, the nurse should hold the next dose of furosemide and check the potassium level before administering the medication.
Rationale:
(a) is incorrect because monitoring of calcium is not necessary with furosemide.
(b) is incorrect because monitoring of glucose is not necessary with furosemide.
(d) is incorrect because monitoring of sodium is not necessary with furosemide.
Question 20.
The nurse in the pediatric cardiac intensive care unit (ICU) is caring for a i-month-old female patient who has been admitted for confirmation of ventricular septal defect. When assessing the infant, the nurse expects to find which of the following?
(a) Bradycardia at rest
(b) Bounding upper extremity peripheral pulses
(c) Activity related cyanosis
(d) Murmur at left sternal border
Answer:
(d) Murmur at left sternal border
Explanation:
Ventricular septal defect (VSD) occurs when the hole between the ventricles of the heart does not close before the fetus is born, allowing blood between the ventricles to mix and decreasing oxygenation of the blood. A loud, harsh murmur at the left sternal border is an expected finding in a child with VSD.
Rationale:
(a) is incorrect because pediatric bradycardia at rest is characteristic of AV block, not VSD.
(b) is incorrect because bounding upper extremity peripheral pulses are characteristic of coarctation of the aorta, not VSD.
(c) is incorrect because activity-related cyanosis is characteristic of Tetralogy of Fallot, not VSD.
Question 21.
The nurse in the pediatric unit is providing discharge instructions to the parents of a 4-year-old boy with Tetralogy of Fallot. When teaching the parents about hypercyanotic spells (“tet spells”), the nurse tells the parents they should:
(a) Call the healthcare provider immediately
(b) Use a calm, comforting approach
(c) Lay the child supine
(d) Take the child to the emergency room
Answer:
(b) Use a calm, comforting approach
Explanation:
Tetralogy of Fallot (TOF) is a congenital heart defect that includes ventricular septal defect, pulmonary stenosis, hypertrophy of the right ventricle, and an overriding aorta. In TOF, hypercyanotic spells (“tet spells”) result in extreme bluish discoloration of mucous membranes and skin. Parents must maintain a calm and comforting approach and place the child in the knee-to-chest position, which will help relieve the dyspnea.
Rationale:
(a) is incorrect because notifying the healthcare provider is not the first action for the parents to take. A calm approach is helpful in relieving the dyspnea the child is experiencing, and proper positioning of the child is the priority. The healthcare provider will assess frequency of “tet” spells at regular clinic visits.
(c) is incorrect because the supine position is not the proper position for reducing cardiac workload associated with “tet” spells in TOF.
(d) is incorrect because taking the child to the emergency room is not necessary unless profound hypoxia occurs after proper positioning.
Question 22.
A 3-month-old infant has been prescribed digoxin to be given at home for chronic tachyarrhythmia. When teaching the mother about digoxin, which of the following statements is appropriate for the nurse to include?
(a) “Be sure to report blurred vision to the healthcare provider immediately.”
(b) “You can expect your baby’s heart rate to be elevated while taking this medication.”
(c) “Vomiting for two or more feedings may be a sign of toxicity and should be reported immediately.”
(d) “Bulging of the anterior fontanel may be a sign that the digoxin level is too low.”
Answer:
(c) “Vomiting for two or more feedings may be a sign of toxicity and should be reported immediately.”
Explanation:
Signs of digoxin toxicity include blurred vision, yellow-green visual spots, nausea, and vomiting, but only objective symptoms such as vomiting can be assessed by the mother of a 3-month-old.
Rationale:
(a) is incorrect because blurred vision cannot be assessed in a 3-month-old patient.
(b) is incorrect because digoxin decreases the heart rate.
(d) is incorrect because bulging of the anterior fontanel (which indicates increased intracranial pressure) is not related to administration of digoxin to an infant.
Question 23.
The nurse is caring for a 2-year-old who is recovering from cardiac catheterization for diagnosis of a congenital heart defect. When assessing the child, which of the following indicates immediate action by the nurse is warranted?
(a) Decreased pulse
(b) Decreased urine output
(c) Respirations 34 per minute
(d) Bleeding from catheter site
Answer:
(d) Bleeding from catheter site
Explanation:
Cardiac catheterization is performed in pediatric patients to locate and identify abnormalities of the heart. Bleeding from the catheter site could become threatening and warrants immediate action by the nurse. Pressure should be applied to the site immediately.
Rationale:
(a) is incorrect because the greatest concern after a cardiac catheterization .is hemorrhage, which would present with increased pulse, not decreased.
(b) is incorrect because decreased urine output should be further assessed, but urine output is not a greater concern than potential hemorrhage. This finding could be due to the child lying supine during and after the catheterization.
(c) is incorrect because the normal respiratory rate for a toddler is 20 to 40 per minute.
Question 24.
The nurse is caring for a 9-year-old boy admitted for myocarditis experiencing tachycardia. The healthcare provider has prescribed digoxin. Before administering the digoxin, the nurse must assess which of the following?
(a) Apical pulse
(b) Urine output
(c) Bilateral pulse equality
(d) Blood pressure
Answer:
(a) Apical pulse
Explanation:
Digoxin is a cardiac glycoside medication that is administered to decrease heart rate and improve myocardial contractility. This drug should not be administered if the child’s is bradycardic. The most accurate method of measuring heart rate in a child is assessing the apical pulse. Normal pulse for a 9-year-old is 60 to 95 beats per minute.
Rationale:
(b) is incorrect because urine output assessment is not a priority before administering digoxin.
(c) is incorrect because pulse equality assessment is not a priority before administering digoxin to a child.
(d) is incorrect because blood pressure assessment is not necessary before administering digoxin.
Question 25.
The nurse in the pediatric intensive care unit (PICU) is assessing a 5- year-old boy admitted with heart failure. The boy weighs 40 lbs. When assessing the child, which of the following indicates adequate cardiac output?
(a) Urine output 30 mL/hr
(b) Heart rate 120 bpm
(c) Capillary refill 6 to 7 seconds
(d) Bilateral crackles heard on auscultation
Answer:
(a) Urine output 30 mL/hr
Explanation:
Heart failure is inability of the heart to pump effectively, causing the backing up of blood within the cardiovascular system, which can lead to edema and decrease urine output. Minimal hourly urine output should be 1-2 mL/kg/hr. in children. This child weighs 40 Ibs is 8.14 kg. Normal urine output for this child should be 8-36mL/hr., so 30 mL/hr. indicates the heart is pumping effectively and cardiac output is adequate.
Rationale:
(b) is incorrect because a 5-year-old’s heart rate should be between 60 and 95 bpm. Tachycardia suggests the heart is having to beat faster than normal to maintain adequate perfusion throughout the body. This is an indication that cardiac output is not adequate.
(c) is incorrect because capillary refill should be less than 2 seconds. Delayed capillary refill indicates decreased cardiac output.
(d) is incorrect because crackles are abnormal and could indicate worsening heart failure or hypervolemia.