PEDS Nursing
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen
is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following
actions would the nurse do first?
a) obtain an order for sedation for the child
b) assess for an irregular heart rate and rhythm
c) explain to the child that it will only hurt for a short time
d) place the child in knee-to-chest position - ANSWERAnswer: D.
the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-
to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the
volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child
with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen
content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left
ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective,
then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart
rate and rhythm. Explaining tho the child that it will only hurt for a short time does nothing to alleviate
hypoxia.
The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases
the response on the understanding that clubbing is due to which of the following?
a) Anemia.
b) Peripheral hypoxia.
c) Delayed physical growth.
d) Destruction of bone marrow. - ANSWERAnswer: B
Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in
the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue
fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as
the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not
,anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may
be small for his or her chronological age, but clubbing does not result from slow physical growth. Destruction
of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively
producing erythrocytes to compensate for the chronic hypoxia.
A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the
nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that
the x-ray film will do which of the following?
a. Show bones of chest but not the heart
b. Evaluate the vascular anatomy outside of the heart
c. Show a graphic measure of electrical activity of the heart
d. Provide information on heart size and pulmonary blood flow patterns - ANSWERANS: D
Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns. The bones
of the chest are visible on the chest x-ray film, but the heart and blood vessels are also seen. Magnetic
resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the
heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.
John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the
following?
a. Directed at his parents because he is too young to understand
b. Adapted to his level of development so that he can understand
c. Done several days before the procedure so he will be prepared
d. Provide details about the actual procedures so he will know what to expect - ANSWERANS: B
Preoperative teaching should always be directed to the child's stage of development. The caregivers also
benefit from these explanations. The parents may ask additional questions, which should be answered, but
the child needs to receive the information based on developmental level. This age-group will not understand
in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.
A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On
assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the
disease?
a) cracked lips
,b) a normal appearance
c) conjunctival hyperemia
d) desquamation of the skin - ANSWERAnswer: C
In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and
enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of
the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the
convalescent stage, the child appears normal, but signs of inflammation may be present.
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter
insertion site is weaker. The nurse should do which of the following?
a. Elevate affected extremity.
b. Notify practitioner of the observation.
c. Record data on assessment flow record.
d. Apply warm compresses to insertion site. - ANSWERANS: C
The pulse distal to the catheterization site may be weaker for the first few hours after catheterization, but
should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is
maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are
neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are
not indicated.
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that
her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate
initial nursing action is which of the following?
a. Notify the physician.
b. Place child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d. Apply direct pressure above catheterization site. - ANSWERANS: D
When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site
to localize pressure on the vessel puncture. The physician can be notified and a new bandage with more
pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while
the pressure is being maintained. Trendelenburg position would not be a helpful intervention. It would
increase the drainage from the lower extremities.
, The nurse should recognize that congestive heart failure (CHF) is which of the following?
a. Disease related to cardiac defects
b. Consequence of an underlying cardiac defect
c. Inherited disorder associated with a variety of defects
d. Result of diminished workload imposed on an abnormal myocardium - ANSWERANS: B
CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal
filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability
of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital
heart defects in which structural abnormalities result in increased volume load or increased pressures on the
ventricles.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should
do which of the following?
a. Administer oxygen.
b. Record data on nurses' notes.
c. Report data to the practitioner.
d. Place child in high Fowler position. - ANSWERANS: C
One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of
sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen
or a semiupright position may be indicated, the first action is to report the data to the practitioner.
The infant with congestive heart failure (CHF) has a need for:
a. decreased fat.
b. increased fluids.
c. decreased protein.
d. increased calories. - ANSWERANS: D
Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and
respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen
is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following
actions would the nurse do first?
a) obtain an order for sedation for the child
b) assess for an irregular heart rate and rhythm
c) explain to the child that it will only hurt for a short time
d) place the child in knee-to-chest position - ANSWERAnswer: D.
the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-
to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the
volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child
with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen
content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left
ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective,
then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart
rate and rhythm. Explaining tho the child that it will only hurt for a short time does nothing to alleviate
hypoxia.
The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases
the response on the understanding that clubbing is due to which of the following?
a) Anemia.
b) Peripheral hypoxia.
c) Delayed physical growth.
d) Destruction of bone marrow. - ANSWERAnswer: B
Clubbing of the fingers is one common finding in the child with persistent hypoxia leading to tissue changes in
the body because of the low oxygen content of the blood (hypoxemia). It apparently results from tissue
fibrosis and hypertrophy from the hypoxemia and from an increase in capillaries in the area, which occur as
the body attempts to improve blood supply. Clubbing of the fingers is associated with polycythemia, not
,anemia. Polycythemia results from the body's attempt to increase oxygen levels in the tissues. The child may
be small for his or her chronological age, but clubbing does not result from slow physical growth. Destruction
of the bone marrow is not related to this congenital heart malformation. Instead, bone marrow is actively
producing erythrocytes to compensate for the chronic hypoxia.
A chest x-ray examination is ordered for a child with suspected cardiac problems. The child's parent asks the
nurse, "What will the x-ray show about the heart?" The nurse's response should be based on knowledge that
the x-ray film will do which of the following?
a. Show bones of chest but not the heart
b. Evaluate the vascular anatomy outside of the heart
c. Show a graphic measure of electrical activity of the heart
d. Provide information on heart size and pulmonary blood flow patterns - ANSWERANS: D
Chest x-ray films provide information on the size of the heart and pulmonary blood flow patterns. The bones
of the chest are visible on the chest x-ray film, but the heart and blood vessels are also seen. Magnetic
resonance imaging is a noninvasive technique that allows for evaluation of vascular anatomy outside of the
heart. A graphic measure of electrical activity of the heart is provided by electrocardiography.
John is a 6-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be which of the
following?
a. Directed at his parents because he is too young to understand
b. Adapted to his level of development so that he can understand
c. Done several days before the procedure so he will be prepared
d. Provide details about the actual procedures so he will know what to expect - ANSWERANS: B
Preoperative teaching should always be directed to the child's stage of development. The caregivers also
benefit from these explanations. The parents may ask additional questions, which should be answered, but
the child needs to receive the information based on developmental level. This age-group will not understand
in-depth descriptions. School-age children should be prepared close to the time of the cardiac catheterization.
A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease. On
assessment of the child, the nurse expects to note which clinical manifestation of the acute stage of the
disease?
a) cracked lips
,b) a normal appearance
c) conjunctival hyperemia
d) desquamation of the skin - ANSWERAnswer: C
In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and
enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of
the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the
convalescent stage, the child appears normal, but signs of inflammation may be present.
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter
insertion site is weaker. The nurse should do which of the following?
a. Elevate affected extremity.
b. Notify practitioner of the observation.
c. Record data on assessment flow record.
d. Apply warm compresses to insertion site. - ANSWERANS: C
The pulse distal to the catheterization site may be weaker for the first few hours after catheterization, but
should gradually increase in strength. Documentation of the finding provides a baseline. The extremity is
maintained straight for 4 to 6 hours. This is an expected change. The pulse is monitored. If there are
neurovascular changes in the extremity, the practitioner is notified. The site is kept dry. Warm compresses are
not indicated.
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that
her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate
initial nursing action is which of the following?
a. Notify the physician.
b. Place child in Trendelenburg position.
c. Apply a new bandage with more pressure.
d. Apply direct pressure above catheterization site. - ANSWERANS: D
When bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site
to localize pressure on the vessel puncture. The physician can be notified and a new bandage with more
pressure can be applied after pressure is applied. The nurse can have someone else notify the physician while
the pressure is being maintained. Trendelenburg position would not be a helpful intervention. It would
increase the drainage from the lower extremities.
, The nurse should recognize that congestive heart failure (CHF) is which of the following?
a. Disease related to cardiac defects
b. Consequence of an underlying cardiac defect
c. Inherited disorder associated with a variety of defects
d. Result of diminished workload imposed on an abnormal myocardium - ANSWERANS: B
CHF is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal
filling pressures to meet the body's metabolic demands. CHF is not a disease but rather a result of the inability
of the heart to pump efficiently. CHF is not inherited. CHF occurs most frequently secondary to congenital
heart defects in which structural abnormalities result in increased volume load or increased pressures on the
ventricles.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. The nurse should
do which of the following?
a. Administer oxygen.
b. Record data on nurses' notes.
c. Report data to the practitioner.
d. Place child in high Fowler position. - ANSWERANS: C
One of the earliest signs of CHF is tachycardia (sleeping heart rate >160 beats/min) as a direct result of
sympathetic stimulation. The practitioner needs to be notified for evaluation of possible CHF. Although oxygen
or a semiupright position may be indicated, the first action is to report the data to the practitioner.
The infant with congestive heart failure (CHF) has a need for:
a. decreased fat.
b. increased fluids.
c. decreased protein.
d. increased calories. - ANSWERANS: D
Infants with CHF have a greater metabolic rate because of poor cardiac function and increased heart and
respiratory rates. Their caloric needs are greater than those of average infants, yet their ability to take in
