PEDIATRIC NURSING CARE OF CHILD WITH CARDIOVASCULAR DISORDERS

The nurse reviews the child’s record and notes that the child has clubbed fingers. The nurse understands that
the clubbing is most likely caused by:
a. Peripheral hypoxia
b. Delayed physical growth
c. Chronic hypertension n
d. Destruction of bone marrow
ANSWER: A
Tetralogy of Fallot is involves four anomalies: pulmonary stenosis, VSD (usually large), dextroposition
(overriding) of the aorta, and hypertrophy of right ventricles. Because of the pulmonary stenosis, pressure builds
up in the right side of the heart. Blood then shunts from this area of increased pressure into the left ventricle and
the overriding aorta. This shunting causes the mixture of oxygenated and unoxygenated blood thus the child may
exhibit cyanosis that worsens with activity. Clubbing, a thickening and flattening of the tips of the fingers and
toes, is thought to occur because of a chronic tissue hypoxia and polycythemia. Options B, C and D do not cause
clubbing.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 1304.
2. Which of the following should the nurse expect to include in the plan of care of a child diagnosed with tetralogy
of fallot who has undergone corrective surgery?
a. 2 to 3 g of sodium in the diet each day
c. Visits limited to a selected few
b. Physical activity restrictions
d. Assignment to an isolation room
ANSWER: A
Because of the hemodynamic changes that occur with open heart surgical repair, particularly with septal defects,
transient congestive heart failure may develop. Therefore, the child’s sodium intake typically is restricted to 2 to
3 g/day. Activity restrictions are inappropriate, typically, the child is encouraged to walk in the halls of the unit.
Visitors are not restricted unless the pediatric unit has restrictive visiting policies. The child can be placed in a
room with other children who are not contagious. After correction of the defect, the risk for infection in the child
is the same as that for any postoperative client.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition Page 1305.
SITUATION: Congenital heart defect is the most common form of cardiac disease in children.
3. When performing an infant’s admission examination, the nurse notes all the following abnormal findings.
Which one is the most common sign of heart disease that the nurse should assess?
a. Diastolic murmur
b. Circumoral cyanosis
c. Hypertension
d. Tachycardia
ANSWER: D
Majority of the infants with CHD have tachycardia or a heart rate above 160 beats per minute. This is often the
first sign of CHD that the nurse can assess. Circumoral cyanosis, hypertension and diastolic murmur may or may
not be present depending on the type and severity of the defect.
4. Upon assessment, an infant with the coarctation of the aorta would be expected to have:
a. Edema
b. Absence of palpable femoral pulses
c. Strong pedal pulses
d. Shortness of breath
ANSWER: B
Coarctation of the aorta is the narrowing of the lumen of the aorta due to a constricting band. It occurs most
often in boys than in girls and is the leading cause of congestive heart failure in the few months of life. If the
coarctation of the aorta is slight, absence of palpable femoral pulses may be the only symptom.
5. Tetralogy of Fallot is a defect that results in decreased pulmonary blood flow because:
a. Deoxygenated blood is shunted from the right ventricle to the left ventricle through and the overriding aorta
b. Deoxygenated blood is shunted from the right atrium to the left atrium and increased pressure from aortic stenosis
c. Deoxygenated blood is forced into the left atrium through a patent ductus arteriosus
d. Deoxygenated blood continuopunly scirculates from the right ventricle to the lungs and back to the right ventricle
ANSWER: A
This is a description of the shunting involved in TOF that causes the altered hemodynamics.
6. A child with Tetralogy of Fallot who has not had surgical repair may assume a posturing position as a
compensatory mechanism. The position automatically assumed by the child would be:
a. prone
b. Kneeling
c. Supine
d. Squatting
ANSWER: D
Squatting allows for improved venous return of the blood flow from the lower extremities. This is a position that
other children rarely assume. Squatting gives the physiologic relief to an overstressed heart by trapping blood in
the lower extremities. Unfortunately, this position can leave an insufficient amount of total circulating blood for
the body to oxygenate and deliver to major body organs.
7. A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective
surgery. Preoperatively, what is the most important nursing goal