Exam (elaborations) HESI Cardiovascular defect- PEDS

Which findings support the nurse's initial observation that Keith has an alteration of cardiac function? - ANSWER Weak peripheral pulses Infants with congenital defects often have heart failure. Peripheral pulses are weak due to inability of the heart to pump adequately. The nurse determines that Keith has an alteration of pulmonary function based on exercise intolerance (fatigue during feeding) and which of the following signs? - ANSWER Intercostal retractions Retractions are observed in heart failure, especially in infants The nurse auscultates Keith's lungs and hears a loud holosystolic murmur at the base of the left sternal border. The nurse recognizes this murmur is associated with which congenital heart defect? - ANSWER Ventricular septal defect This murmur is characteristic of ventricular septal defect. The nurse recognizes that Mrs. Rorberts' concerns are consistent with postpartum depression, as well as anxiety related to Keith's illness. How can the nurse communicate physical assessment findings in a therapeutic manner for this mother? - ANSWER "It's difficult to cope with the loss of the robust baby you anticipated. However, I can see that your baby is well cared for." This statement acknowledges her grief and gives an empowering message by validating her caring skills. Which explanation provides an accurate but nonthreatening description of the cardiac catheterization procedure? - ANSWER A small catheter will be guided through the skin to the heart. Films will be taken to allow the physician to determine the best way to treat your baby. The terms "small" and "guided" are accurate but nonthreatening. The message also stresses healing. How should the nurse interpret these findings? - ANSWER Respiratory acidosis and hypoxemia The client has pulmonary hypertension as evidenced by the prominent pulmonary arteries seen on an x-ray. This finding is often associated with respiratory acidosis and hypoxia. In addition to treating the hypoxia, what additional benefit is there to the administration of oxygen to this client? - ANSWER Decreased pulmonary vascular resistance Oxygen is a vasodilator, thus it decreases pulmonary vascular resistance, which, in turn, will reduce the workload on the heart. Keith is stabilized and is prepared for cardiac catheterization. He returns to the unit following a right sided catheterization via the right femoral vein. Which postcatheterization nursing care takes priority? - ANSWER Conduct neurovascular assessments of the lower extremities