Nokea
A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?
- A. 60 beats/min
- B. 90 beats/min
- C. 100 beats/min
- D. 120 beats/min
Correct Answer: B
Rationale: For infants and young children, digoxin is withheld if the 1-minute apical pulse is below 90 beats/min to prevent toxicity. A rate of 60 is the adult threshold, and 100-120 beats/min are acceptable for administration.
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A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action?
- A. Assess for neurologic defects.
- B. Prepare the family for imminent death.
- C. Begin cardiopulmonary resuscitation.
- D. Place the child in the kneechest position.
Correct Answer: D
Rationale: Placing the infant in the knee-chest position increases systemic vascular resistance, reducing the hypercyanotic spell. Oxygen and morphine may follow, but this is the first action. Neurologic defects, CPR, or preparing for death are inappropriate initial responses.
Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infants status, which finding is indicative of achieving this goal?
- A. Irritability when awake
- B. Capillary refill of more than 5 seconds
- C. Appropriate weight gain for age 18
- D. Positioned in high Fowler position to maintain oxygen saturation at 90%
Correct Answer: C
Rationale: Appropriate weight gain indicates successful feeding and reduced caloric loss, reflecting decreased cardiac demand. Irritability and prolonged capillary refill suggest ongoing HF, and high Fowler positioning aids breathing but doesn?t confirm reduced cardiac strain.
The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication?
- A. Hypoxemia
- B. Right-to-left shunt of blood
- C. Decreased workload on the left side of the heart
- D. Pulmonary vascular congestion
Correct Answer: D
Rationale: PDA causes left-to-right shunting from the aorta to the pulmonary artery, leading to pulmonary vascular congestion. Surgery prevents this complication. Hypoxemia is linked to mixed flow defects, the shunt is left-to-right, and PDA increases left heart workload.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk?
- A. Minimize seizures.
- B. Prevent dehydration.
- C. Promote cardiac output.
- D. Reduce energy expenditure.
Correct Answer: B
Rationale: Preventing dehydration reduces stroke risk in hypoxic children with polycythemia, as dehydration increases blood viscosity. Seizure control, cardiac output, and energy expenditure are important but don?t directly address stroke risk.
What blood flow pattern occurs in a ventricular septal defect?
- A. Mixed blood flow
- B. Increased pulmonary blood flow
- C. Decreased pulmonary blood flow
- D. Obstruction to blood flow from ventricles
Correct Answer: B
Rationale: A ventricular septal defect allows blood to shunt from the high-pressure left ventricle to the lower-pressure right ventricle, increasing pulmonary blood flow. It?s a one-way shunt, not mixed flow, doesn?t obstruct ventricular outflow, and isn?t associated with decreased flow.