Study Guide Midterm Flashcards
What is a common, serious complication of rheumatic fever?
A.
Pulmonary hypertension.
B.
Cardiac valve damage.
C.
Seizures.
D.
Cardiac arrhythmias.
B.
Cardiac valve damage.
The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?
a) “We need to avoid a tub bath for the next 3 days.”
b) “Strenuous activity should be limited for the next 3 days.”
c) “The feeling of the heart skipping a beat is common.”
d) “We need to watch for changes in skin color or difficulty breathing.”
c) “The feeling of the heart skipping a beat is common.”
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A young child with tetralogy of Fallot may assume a posturing position as a compensatory mechanism. What position would the nurse expect the child to assume?
A. Low Fowler’s
B. Prone
C. Supine
D. Knee-chest
D. Knee-chest
The squatting or knee-chest position decreases the amount of blood returning to the heart and allows the child time to compensate. Low Fowler’s position would assist with respiratory issues but would not assist with the need for cardiac compensation. Prone does not offer any advantage to the child. Supine does not offer any advantage to the child.
The nurse is caring for a child whose cardiac condition is classified as a mixed-blood cardiac defect. What diagnosis would the nurse expect to see on the patient’s chart?
A. Pulmonic stenosis
B. Atrial septal defect
C. Patent ductus arteriosus
D. Transposition of the great arteries
D. Transposition of the great arteries
Transposition of the great arteries allows the mixing of blood in the heart. Pulmonic stenosis is classified as an obstructive defect. Atrial septal defect is classified as a defect with increased pulmonary blood flow. Patent ductus arteriosus is classified as a defect with increased pulmonary blood flow.
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
A.
Offer the child clear liquids for the first 24 hr.
B.
Give the child acetaminophen for discomfort.
C.
Assist the child in taking a tub bath for the first 3 days.
D.
Keep the child home for 1 week.
B.
Give the child acetaminophen for discomfort.
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child’s proper recovery. The correct instruction to include is option B: “Give the child acetaminophen for discomfort.”
6 week old with VSD. came in about 1 month ago, history of not eating, weight loss 1 month ago, and starting up on digoxin 2 times a day. Currently, Is in ER for periorbital edema, not eating, vomiting. Today presenting awaken, no nasal flarring, tachypnic, apical pulse is strong, VSD murmur heard, normal rhythm, and today the edema is resolved. Fontanelle is soft, urine output is adequate but alittle low (1mg/kg/hr). No retraction, pulses are strong. Pink is color, edema is resolved.
Experiencing Digoxin toxicity → usually digoxin is given 1x a day i. Monitor heart rate → make sure the rate does not go lower
ii. look at EKG to look at his PR interval to look for prolonging (low down the SA node to AV node → which is the distance between PR interval)
iii. Monitor digoxin levels in blood→ blood work to make sure the levels are cleared
iv. Signs of toxicity → vomiting
2 week old, has TOF. Assessment at 2 oclock → warm, pale dry skin, unlabored
respiration, history of fatigue with feedings. At 3 oclock → cyanotic, agitated, skin is cool to touch, present with nasal flaring and retractions, tachypnea. hypercyanotic spasm of the infidibulum areas right below the pulmonary
a. How to treat this baby? Experiencing TET spells
i. oxygen supplementation
ii. bend the knees to chest for 2 weeks old (older kids squat on playground)
iii. administer morphine (reduce spasm in the heart by dilatiing vessels)
0700
Adolescent alert and oriented, resting in bed in supine position with their legs straight. Pressure dressing to right femoral area dry and intact. Bilateral lower extremities warm to touch with equal posterior tibial and dorsalis pedis pulses palpated. Reports pain as
0 on a scale of 0 to10
0730
Adolescent awake, resting in supine position with their legs straight. Dressing to right femoral area saturated with bloody drainage. Posterior tibial and dorsalis pedis pulses of right extremity slightly diminished compared to the left extremity. Right lower extremity cool and pale in color. Reports pain as 2 on a scale of 0 to10
Which of the following assessment findings should the nurse report to the provider?
Select the 4 findings that the nurse should report to the provider.
Pressure dressing
Adolescent’s position
Pain
Blood pressure
Pulses of right extremity
Right lower extremity color and warmth
Respiratory rate
Apical pulse
Pressure Dressing
Pulses of right extremity
Blood pressure
Right lower extremity color and warmth
A nurse is caring for a 4 year
old child who has an atrial septal defect ASD
Medical History Vital Signs Nurses’ Notes
Medical History
The child was diagnosed early in infancy with a small ASD near the center of the septum. The ASD has remained open, and the child is beginning to have increased pulmonary blood flow per echocardiogram
1month ago.
Admitted today to cardiac catheterization procedure unit for transcatheter closure of the ASD using a septal occluder.
Which of the following assessment findings at
1600 indicate that the expected outcomes have been met?
Click to highlight the statements in the nurse’s notes which show achievement of the expected outcomes. To deselect a statement, click on the statement again.
Normalize temperature of the baby
Pressure dressing is dry and intact
Right leg is warm and equal to touch
Pulses are now equal and strong
*encourage to drink something so they don’t get dehydrated
*Treat pain with Tylenol since not too severe
Adolescent with history of rheumatic fever. Dental work last week. Present with fever,
anorexia, tachypnea, lungs are clear, mucus membranes have alittle bit of bruising. He then becomes restless, dyspnea at rest, dull mild chest pain at bilateral route. HR increase, RR increase, o2 went down, BP went down
a. What can you anticipate to be ordered for this child and what should not be done
Possible ineffective endocarditis —> blood cultures and then give antibiotics
— series of 3, 15 min apart
EKG and echocardiogram —> tell if there is any vegetations growing on valve
Does not want the kid to do strenuous activity
Do not want to restrict his dental hygiene —> he can do his normal dental hygiene
— should be on prophylactic antibiotics before any dental procedures
A nurse is assessing a 3-year-old child who has aortic stenosis. WHich of the following findings should the nurse expect? (Select all that apply)
A. Hypotension
B. Bradycardia
C. Clubbing of the nail beds
D. Weak pulses
E. Murmur
A. Hypotension
D. Weak pulses
E. Murmur
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
“Has your son had a sore throat recently?”
“Was your son born with this cardiac defect?”
“Has your child had any injuries recently?”
“Have you given your child aspirin in the past 2 weeks?”
“Has your son had a sore throat recently?”
Ebstein’s anomaly is the apical displacement of which valve?
Tricuspid valve
What are the organism that cause endocarditis a. Strept A
b. Staphylococcus
c. Or both
Streptococcus Viridans
Candida albicans
Staphylococcus aureas
6 month old in cardiac cath → assessing before the cath lab
a. Assessment shows bounding extremity in upper and lower in lower
i. Possible complication → coarctation of the aorta
- Two actions that can be anticipated before going into cath lab
a. Anticipate that they start on an inotrophic med →
epinephrine, norephinephrine (presser)
b. Ventilate the baby before - Post procedure → monitor the BP for possible systemic hypertension and monitor lung sounds
a. All of a sudden the blood circulating through lower extremity, it can cause CHF
i. Check lungs to see if fluids backs up into lungs
How do you define family center care
make sure to include parents, child, and careteam including nurse, provider, and rest of the health care team (collaborative partnership)
What kind of benefits can a child get from hospitalization
a. Support and recovery from their illness
b. Child will learn how to master their stress and coping skill
c. It is also a chance of socialization experience
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?
Your need for sleep will increase during periods of growth
Now you are providing health promotion to an adolescent, what would you include
a. Anything that is preventative education
b. Encourage sleep and that increase sleep helps with increased growth patterns
What will help a toddler that is having trouble sleeping
a. Provide bed time rituals
A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client’s psychosocial needs according to Erikson?
A.
Discourage visits from the client’s friends
B.
Provide a daily session with a play therapist
C.
Encourage the client to complete school work
D.
Vary the child’s schedule each day
C.
Encourage the client to complete school work
A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?
a) imaginary playmates
b) Erikson’s stage of initiative vs guilt
c) Demonstrations of sexual curiosity
d) negative behaviors characterized by the need for autonomy
d) negative behaviors characterized by the need for autonomy
Assertion of autonomy is seen in toddlers as they begin their language and social development.
The primary critical observation for Apgar scoring is the:
A. Heart rate
B. Respiratory rate
C. Presence of meconium
D. Evaluation of the Moro reflex
A: The heart rate is vital for life and is the most critical observation in Apgar scoring.
Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?
a. Warming the crib pad
b. Closing the doors to the room
c. Drying the infant with a warm blanket
d. Turning on the overhead radiant warmer
c. Drying the infant with a warm blanket
Dry the child with a blanket to keep the temperature from dropping
What is the sequence of abdominal assessment
a. Inspect, auscultate, superficial palpate, deep palpate
What to expect at a 6 month old wellness check
a. Weight 2x increase
b. Posterior fontanelle as closed (closes at 2 months and anterior closes at 12-18 months)
Sequence of VS for newborn
a. Count respiration
b. Listen to apical heart rate
c. Blood pressure or temperature
Where to ascultate infants heart rate
a. Apical pulse
A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider?
a) Inability to raise head when in prone position
b) Inability to sit without support
c) Inability to pick up an object with her fingers
d) Inability to bring an object to her mouth
a) Inability to raise head when in prone position
4 months old → put things in mouth
8 months old → sit without support
6 months old -> can pick up an object with fingers
3 month old should be able to raise head when in prone position.
Teaching CNA about vitals on an infant
a. Respiratory teaching → count for 1 minute due to the respiration not being consistent
