Chapter 19: Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

1. The nurse is conducting a physical examination of a child with a ventricular septal defect. Which finding would the nurse expect to assess? A) Right ventricular heave B) Holosystolic harsh murmur along the left sternal border C) Fixed split-second heart sound D) Systolic ejection murmur - Ans: B Feedback: With ventricular septal defects, there is often a characteristic holosystolic harsh murmur along the left sternal border. Right ventricular heave, fixed split-second heart sound, and systolic ejection murmur are typically found with atrial septal defects. 2. The nurse is administering digoxin as ordered and the child vomits the dose. What should the nurse do next? A) Contact the physician. B) Offer a snack and administer another dose. C) Immediately administer another dose. D) Administer next dose as ordered in 12 hours. - Ans: D Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1 hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should not give a second dose and should wait until the next scheduled dose. It is not necessary to contact the physician. 3. The nurse is caring for an infant with suspected patent ductus arteriosus. Which assessment finding would the nurse identify as helping to confirm this suspicion? A) Thrill at the base of the heart B) Harsh, continuous, machine-like murmur under the left clavicle C) Faint pulses D) Systolic murmur best heard along the left sternal border - Ans: B Feedback: With patent ductus arteriosus, a harsh, continuous, machine-like murmur (usually loudest under the left clavicle) is heard at the first and second intercostal spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the left sternal border point to aortic stenosis. 4. The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of th