Chapter 23 The Child with Cardiovascular
Dysfunction Hockenberry: Wong's
Essentials of Pediatric Nursing, 10th
Edition
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely
cyanotic
during a routine blood draw. Which interventions should the nurse implement?
Place in order from
the highest-priority intervention to the lowest-priority intervention. Provide the
answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line. - Answer b.
Place the infant in knee-chest position.
a. Administer 100% oxygen by blow-by.
d. Give morphine subcutaneously or by an existing intravenous line.
c. Remain calm.
,ANS:
b, a, d, c
Hypercyanotic spells, also referred to as blue spells or tet spells because they are
often seen in infants
with tetralogy of Fallot, may occur in any child whose heart defect includes
obstruction to pulmonary
blood flow and communication between the ventricles. The infant becomes
acutely cyanotic and
hyperpneic because sudden infundibular spasm decreases pulmonary blood flow
and increases right-to-
left shunting. Because profound hypoxemia causes cerebral hypoxia,
hypercyanotic spells require prompt
assessment and treatment to prevent brain damage or possibly death. The infant
should first be placed in
the knee-chest position to reduce blood returning to the heart. Next 100% oxygen
is given to alleviate the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last,
the nurse should remain
calm.
DIF: Cognitive Level: Apply REF: p. 741
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
,1. A chest radiograph film is ordered for a child with suspected cardiac problems.
Thechild's parent asks the nurse, "What will the radiograph show about the
heart?" What knowledge
about the x-ray should the nurse include in the response to the parents?
a. Bones of chest but not the heart
b. Measurement of electrical potential generated from heart muscle
c. Permanent record of heart size and configuration
d. Computerized image of heart vessels and tissues - Answer c. Permanent record
of heart size and configuration
ANS: C
A chest radiograph will provide information on the heart size and pulmonary
blood-flow patterns. It will
provide a baseline for future comparisons. The heart will be visible, as well as the
sternum and ribs.
Electrocardiography (ECG) measures the electrical potential generated from heart
muscle.
Echocardiography will produce a computerized image of the heart vessels and
tissues by using sound
waves.
DIF: Cognitive Level: Understand REF: p. 738
, TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is assessing a child after a cardiac catheterization. Which
complication should
the nurse be assessing for?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure - Answer a. Cardiac arrhythmia
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced
dysrhythmias occurring
during the procedure. These are usually transient. Hypostatic pneumonia, heart
failure, and rapidly
increasing blood pressure are not risks usually associated with cardiac
catheterization.
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