Chapter 23, The Child with Cardiovascular Dysfunction Hockenberry Wong's Essentials of Pediatric Nursing, 10th Edition.
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a routine blood draw. Which interventions should the nurse implement? Place in order from the highest-priority intervention to the lowest-priority intervention. Provide the answer using lowercase letters separated by commas (e.g., a, b, c, d).
- Administer 100% oxygen by blow-by.
- Place the infant in knee-chest position.
- Remain calm.
- Give morphine subcutaneously or by an existing intravenous line. - ANSWER-b.
- Administer 100% oxygen by blow-by.
- Give morphine subcutaneously or by an existing intravenous line.
- Remain calm.
Place the infant in knee-chest position.
ANS:
b, a, d, c Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in infants with tetralogy of Fallot, may occur in any child whose heart defect includes obstruction to pulmonary blood flow and communication between the ventricles. The infant becomes acutely cyanotic and
hyperpneic because sudden infundibular spasm decreases pulmonary blood flow and increases right-to- left shunting. Because profound hypoxemia causes cerebral hypoxia, hypercyanotic spells require prompt
assessment and treatment to prevent brain damage or possibly death. The infant should first be placed in the knee-chest position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate the hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse should remain calm.DIF: Cognitive Level: Apply REF: p. 741 1 / 3
TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
- A chest radiograph film is ordered for a child with suspected cardiac problems.
Thechild's parent asks the nurse, "What will the radiograph show about the heart?" What knowledge about the x-ray should the nurse include in the response to the parents?
- Bones of chest but not the heart
- Measurement of electrical potential generated from heart muscle
- Permanent record of heart size and configuration
- Computerized image of heart vessels and tissues - ANSWER-c. Permanent record of
heart size and configuration
ANS: C
A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It will provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs.Electrocardiography (ECG) measures the electrical potential generated from heart muscle.Echocardiography will produce a computerized image of the heart vessels and tissues by using sound waves.DIF: Cognitive Level: Understand REF: p. 738 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
- The nurse is assessing a child after a cardiac catheterization. Which complication
should the nurse be assessing for?
- Cardiac arrhythmia
- Hypostatic pneumonia
- Heart failure
- Rapidly increasing blood pressure - ANSWER-a. Cardiac arrhythmia
ANS: A
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Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.DIF: Cognitive Level: Apply REF: p. 739 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
- José is a 4-year-old child scheduled for a cardiac catheterization. What should be
included in preoperative teaching?
- Directed at his parents because he is too young to understand
- Detailed in regard to the actual procedures so he will know what to expect
- Done several days before the procedure so that he will be prepared
- Adapted to his level of development so that he can understand - ANSWER-ANS: D
- Adapted to his level of development so that he can understand
Preoperative teaching should always be directed at the child's stage of development.The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level.Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.DIF: Cognitive Level: Apply REF: p. 739 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance
- Which explanation regarding cardiac catheterization is appropriate for a preschool
child?
- Postural drainage will be performed every 4 to 6 hours after the test.
- It is necessary to be completely "asleep" during the test.
- The test is short, usually taking less than 1 hour.
- When the procedure is done, you will have to keep your leg straight for at least
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