, Congenital Heart Disease
Page 1
1. Clinical Manifestations
Billy is admitted to the pediatric unit for treatment of the CHF and is to be seen
by a pediatric cardiologist for further cardiac assessment. The nurse interviews
Teresa and Aaron and completes Billy's admission assessment.
2. 1.ID: 6975229789
Which clinical manifestations would the nurse expect to assess in an infant
diagnosed with ventricular septal defect (VSD)?
A. Normal S1 and S2 heart sounds with no audible murmur or
palpable thrill.
These would not be expected.
B. Tachypnea and grunting with intercostal and subcostal
retractions. Correct
These manifestations are due to the increased workload of the heart and fluid
buildup in the lungs.
C. Extreme pallor and porcelain-like skin.
These are associated with iron-deficiency anemia, not VSD.
D. Excessive bruising, lymphadenopathy, and poor skin turgor.
These findings may be associated with leukemia.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. The nurse continues Billy's admission assessment and obtains subjective
data from Billy's parents concerning his normal routine for feeding, bathing, and
playing.
4. 2.ID: 6975229793
Which statement by Teresa supports Billy's diagnosis of CHF?
A. "Billy never seems to get full even when I breastfeed him for a
long time." Correct
One of the earliest signs of CHF in an infant is difficulty eating. Feedings take
longer, and less is consumed while more energy is expended. The infant may
appear hungry and irritable soon after a feeding.
B. "He is always in a great mood, but he just will not go to sleep
for more than 2 hours."
An infant with CHF fatigues more easily, sleeps a lot of the time, and is
usually irritable and lethargic.
C. "Billy has a bluish tinged color around his lips, and his little
fingers are blue and cold."
, CHF and VSD are acyanotic heart conditions. Therefore, the infant will not
exhibit any cyanosis.
D. "My son has many nosebleeds, and his gums bleed after I feed
him."
An infant with CHF will not typically have any bleeding tendencies.
Correct
Awarded 1.0 points out of 1.0 possible points.
Page 2
1. Diagnostic Tests
The pediatric cardiologist schedules a cardiac catheterization for the next day.
The pediatric nurse discusses the procedure with the parents.
2. 3.ID: 6975230633
What should the nurse include when teaching Billy's parents about post-
procedure care?
A. Advise the parents that vital signs will be taken every 4 hours
after Billy returns to the room.
After cardiac catheterization, vital signs are obtained every 15 minutes
for the first hour and then every hour.
B. Instruct the parents on the technique they should use to assess
Billy's incision site.
Assessment of the incision is a nursing responsibility. It should not be
delegated to the parents.
C. Explain that they will need to hold Billy in the prone position
after the procedure.Correct
Billy's leg that will be used as the femoral artery insertion site must be
kept straight. The infant is placed prone in the lap to help keep the leg
straight and to prevent hematoma formation and subsequent
hemorrhage.
D. Discuss the reason for placing Billy in a car seat for 6 hours
post-procedure.
He would not be allowed to sit up in a car seat.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. As the nurse is obtaining informed consent for Billy's cardiac
catheterization, Aaron says, "I am still not exactly sure why the doctor has
to do the test."
4. 4.ID: 6975230636
Which action should the nurse implement?
Page 1
1. Clinical Manifestations
Billy is admitted to the pediatric unit for treatment of the CHF and is to be seen
by a pediatric cardiologist for further cardiac assessment. The nurse interviews
Teresa and Aaron and completes Billy's admission assessment.
2. 1.ID: 6975229789
Which clinical manifestations would the nurse expect to assess in an infant
diagnosed with ventricular septal defect (VSD)?
A. Normal S1 and S2 heart sounds with no audible murmur or
palpable thrill.
These would not be expected.
B. Tachypnea and grunting with intercostal and subcostal
retractions. Correct
These manifestations are due to the increased workload of the heart and fluid
buildup in the lungs.
C. Extreme pallor and porcelain-like skin.
These are associated with iron-deficiency anemia, not VSD.
D. Excessive bruising, lymphadenopathy, and poor skin turgor.
These findings may be associated with leukemia.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. The nurse continues Billy's admission assessment and obtains subjective
data from Billy's parents concerning his normal routine for feeding, bathing, and
playing.
4. 2.ID: 6975229793
Which statement by Teresa supports Billy's diagnosis of CHF?
A. "Billy never seems to get full even when I breastfeed him for a
long time." Correct
One of the earliest signs of CHF in an infant is difficulty eating. Feedings take
longer, and less is consumed while more energy is expended. The infant may
appear hungry and irritable soon after a feeding.
B. "He is always in a great mood, but he just will not go to sleep
for more than 2 hours."
An infant with CHF fatigues more easily, sleeps a lot of the time, and is
usually irritable and lethargic.
C. "Billy has a bluish tinged color around his lips, and his little
fingers are blue and cold."
, CHF and VSD are acyanotic heart conditions. Therefore, the infant will not
exhibit any cyanosis.
D. "My son has many nosebleeds, and his gums bleed after I feed
him."
An infant with CHF will not typically have any bleeding tendencies.
Correct
Awarded 1.0 points out of 1.0 possible points.
Page 2
1. Diagnostic Tests
The pediatric cardiologist schedules a cardiac catheterization for the next day.
The pediatric nurse discusses the procedure with the parents.
2. 3.ID: 6975230633
What should the nurse include when teaching Billy's parents about post-
procedure care?
A. Advise the parents that vital signs will be taken every 4 hours
after Billy returns to the room.
After cardiac catheterization, vital signs are obtained every 15 minutes
for the first hour and then every hour.
B. Instruct the parents on the technique they should use to assess
Billy's incision site.
Assessment of the incision is a nursing responsibility. It should not be
delegated to the parents.
C. Explain that they will need to hold Billy in the prone position
after the procedure.Correct
Billy's leg that will be used as the femoral artery insertion site must be
kept straight. The infant is placed prone in the lap to help keep the leg
straight and to prevent hematoma formation and subsequent
hemorrhage.
D. Discuss the reason for placing Billy in a car seat for 6 hours
post-procedure.
He would not be allowed to sit up in a car seat.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. As the nurse is obtaining informed consent for Billy's cardiac
catheterization, Aaron says, "I am still not exactly sure why the doctor has
to do the test."
4. 4.ID: 6975230636
Which action should the nurse implement?
