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HESI RN CASE STUDY Congenital Heart Disease – Pediatric
Nursing 2026 UPDATED!!!.
PATIENT SCENARIO
Client: Noah, a 4-month-old male infant
Weight: 5.2 kg (11 lb 7 oz)
Allergies: No known drug allergies
History: Born at 39 weeks gestation. Mother reports that over
the past 3 weeks Noah has become increasingly fatigued during
feedings, often taking only 1–2 oz before falling asleep. He has
also had diaphoresis with feedings and poor weight gain.
Presenting Assessment:
• Temperature: 98.1°F (36.7°C)
• Heart rate: 168 bpm
• Respiratory rate: 64 breaths/min
• Blood pressure: 86/58 mmHg (right arm)
• Oxygen saturation: 85% on room air, 82% while crying
• Weight: 5.2 kg (below 5th percentile)
• Skin: Pale, cool extremities; mild circumoral cyanosis
• Chest: Mild subcostal retractions; no crackles or wheezes
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• Heart: Loud, harsh systolic murmur best heard at the left
lower sternal border; active precordium
• Pulses: Bounding peripheral pulses
• Capillary refill: 3 seconds
• Liver: 2 cm below right costal margin
Diagnostic Studies:
• Chest X-ray: Cardiomegaly with increased pulmonary
vascular markings
• Echocardiogram: Large ventricular septal defect (VSD) with
left-to-right shunt and mild pulmonary hypertension
QUESTIONS & ANSWERS
Question 1
The nurse reviews the assessment findings. Which finding is
most concerning and requires immediate intervention?
A. Heart rate 168 bpm
B. Oxygen saturation 85% on room air
C. Loud, harsh systolic murmur
D. Capillary refill 3 seconds
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Answer: B
Rationale: Oxygen saturation of 85% indicates significant
hypoxemia. The infant is not oxygenating adequately, which can
lead to tissue hypoxia, metabolic acidosis, and worsening
pulmonary hypertension. While tachycardia, murmur, and
delayed capillary refill are relevant findings, hypoxemia is the
priority.
Question 2
The nurse understands that a ventricular septal defect (VSD)
with left-to-right shunting causes which pathophysiologic
change?
A. Decreased pulmonary blood flow
B. Increased pulmonary blood flow and pulmonary congestion
C. Decreased right ventricular workload
D. Systemic cyanosis as a primary finding
Answer: B
Rationale: A left-to-right shunt across a VSD increases
pulmonary blood flow because higher-pressure left ventricle
blood flows into the lower-pressure right ventricle and
pulmonary artery. This leads to pulmonary overcirculation,
congestion, and increased right ventricular workload. Cyanosis
is not the primary early finding in isolated VSD; it may occur
HESI RN CASE STUDY Congenital Heart Disease – Pediatric
Nursing 2026 UPDATED!!!.
PATIENT SCENARIO
Client: Noah, a 4-month-old male infant
Weight: 5.2 kg (11 lb 7 oz)
Allergies: No known drug allergies
History: Born at 39 weeks gestation. Mother reports that over
the past 3 weeks Noah has become increasingly fatigued during
feedings, often taking only 1–2 oz before falling asleep. He has
also had diaphoresis with feedings and poor weight gain.
Presenting Assessment:
• Temperature: 98.1°F (36.7°C)
• Heart rate: 168 bpm
• Respiratory rate: 64 breaths/min
• Blood pressure: 86/58 mmHg (right arm)
• Oxygen saturation: 85% on room air, 82% while crying
• Weight: 5.2 kg (below 5th percentile)
• Skin: Pale, cool extremities; mild circumoral cyanosis
• Chest: Mild subcostal retractions; no crackles or wheezes
, Page |2
• Heart: Loud, harsh systolic murmur best heard at the left
lower sternal border; active precordium
• Pulses: Bounding peripheral pulses
• Capillary refill: 3 seconds
• Liver: 2 cm below right costal margin
Diagnostic Studies:
• Chest X-ray: Cardiomegaly with increased pulmonary
vascular markings
• Echocardiogram: Large ventricular septal defect (VSD) with
left-to-right shunt and mild pulmonary hypertension
QUESTIONS & ANSWERS
Question 1
The nurse reviews the assessment findings. Which finding is
most concerning and requires immediate intervention?
A. Heart rate 168 bpm
B. Oxygen saturation 85% on room air
C. Loud, harsh systolic murmur
D. Capillary refill 3 seconds
, Page |3
Answer: B
Rationale: Oxygen saturation of 85% indicates significant
hypoxemia. The infant is not oxygenating adequately, which can
lead to tissue hypoxia, metabolic acidosis, and worsening
pulmonary hypertension. While tachycardia, murmur, and
delayed capillary refill are relevant findings, hypoxemia is the
priority.
Question 2
The nurse understands that a ventricular septal defect (VSD)
with left-to-right shunting causes which pathophysiologic
change?
A. Decreased pulmonary blood flow
B. Increased pulmonary blood flow and pulmonary congestion
C. Decreased right ventricular workload
D. Systemic cyanosis as a primary finding
Answer: B
Rationale: A left-to-right shunt across a VSD increases
pulmonary blood flow because higher-pressure left ventricle
blood flows into the lower-pressure right ventricle and
pulmonary artery. This leads to pulmonary overcirculation,
congestion, and increased right ventricular workload. Cyanosis
is not the primary early finding in isolated VSD; it may occur
