Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition
MULTIPLE CHOICE
1. A nurse explains how to position an infant with tetralogy of Fallot if the infant suddenly
becomes cyanotic. Which statement by the caregiver leads the nurse to determine the
parent understood the instructions?
a. “If the baby turns blue, I will hold him against my shoulder with his knees bent up
toward his chest.”
b. “If the baby turns blue, I will lay him down on a firm surface with his head lower
than the rest of his body.”
c. “If the baby turns blue, I will immediately put the baby upright in an infant seat.”
d. “If the baby turns blue, I will put the baby in supine position with his head
elevated.”
ANS: A
In the event of a paroxysmal hypercyanotic or “tet” spell, the infant should be placed
in a knee-chest position.
DIF: Cognitive Level: Application REF: 626 OBJ: 6
TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation
2. The parent of a 1-year-old child with tetralogy of Fallot asks a nurse, “Why do my child’s
fingertips look like that?” On what understanding does the nurse base a response?
a. Clubbing occurs as a result of untreated congestive heart failure.
b. Clubbing occurs as a result of a left-to-right shunting of blood.
c. Clubbing occurs as a result of decreased cardiac output.
d. Clubbing occurs as a result of chronic hypoxia.
ANS: D
Clubbing of the fingers develops in response to chronic hypoxia.
, DIF: Cognitive Level: Comprehension REF: 626 OBJ: 3
TOP: Tetralogy of Fallot KEY: Nursing Process Step:
Implementation
3. A child has an elevated antistreptolysin O (ASO) titre. Which combination of symptoms,
in conjunction with this finding, would confirm a diagnosis of rheumatic fever?
a. Subcutaneous nodules and fever
b. Painful, tender joints, and carditis
c. Erythema marginatum and arthralgia
d. Chorea and elevated sedimentation rate
ANS: B
The presence of two major Jones criteria would indicate a high probability of
rheumatic fever.
DIF: Cognitive Level: Application REF: 633 OBJ: 7
TOP: Rheumatic Fever KEY: Nursing Process Step: Data
Collection
4. An infant with heart failure is receiving digoxin (Lanoxin). What does a nurse recognize
as a sign of digoxin toxicity?
a. Restlessness
b. Decreased respiratory rate
c. Increased urinary output
d. Vomiting
ANS: D
Symptoms of digoxin toxicity include nausea, vomiting, anorexia, irregularity in pulse
rate and rhythm, and a sudden change in pulse.
DIF: Cognitive Level: Comprehension REF: 629 OBJ: 6
TOP: Heart Failure KEY: Nursing Process Step: Data Collection
5. Through what does an infant born with hypoplastic left heart syndrome acquire
oxygenated blood?
a. The patent ductus arteriosus
MULTIPLE CHOICE
1. A nurse explains how to position an infant with tetralogy of Fallot if the infant suddenly
becomes cyanotic. Which statement by the caregiver leads the nurse to determine the
parent understood the instructions?
a. “If the baby turns blue, I will hold him against my shoulder with his knees bent up
toward his chest.”
b. “If the baby turns blue, I will lay him down on a firm surface with his head lower
than the rest of his body.”
c. “If the baby turns blue, I will immediately put the baby upright in an infant seat.”
d. “If the baby turns blue, I will put the baby in supine position with his head
elevated.”
ANS: A
In the event of a paroxysmal hypercyanotic or “tet” spell, the infant should be placed
in a knee-chest position.
DIF: Cognitive Level: Application REF: 626 OBJ: 6
TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation
2. The parent of a 1-year-old child with tetralogy of Fallot asks a nurse, “Why do my child’s
fingertips look like that?” On what understanding does the nurse base a response?
a. Clubbing occurs as a result of untreated congestive heart failure.
b. Clubbing occurs as a result of a left-to-right shunting of blood.
c. Clubbing occurs as a result of decreased cardiac output.
d. Clubbing occurs as a result of chronic hypoxia.
ANS: D
Clubbing of the fingers develops in response to chronic hypoxia.
, DIF: Cognitive Level: Comprehension REF: 626 OBJ: 3
TOP: Tetralogy of Fallot KEY: Nursing Process Step:
Implementation
3. A child has an elevated antistreptolysin O (ASO) titre. Which combination of symptoms,
in conjunction with this finding, would confirm a diagnosis of rheumatic fever?
a. Subcutaneous nodules and fever
b. Painful, tender joints, and carditis
c. Erythema marginatum and arthralgia
d. Chorea and elevated sedimentation rate
ANS: B
The presence of two major Jones criteria would indicate a high probability of
rheumatic fever.
DIF: Cognitive Level: Application REF: 633 OBJ: 7
TOP: Rheumatic Fever KEY: Nursing Process Step: Data
Collection
4. An infant with heart failure is receiving digoxin (Lanoxin). What does a nurse recognize
as a sign of digoxin toxicity?
a. Restlessness
b. Decreased respiratory rate
c. Increased urinary output
d. Vomiting
ANS: D
Symptoms of digoxin toxicity include nausea, vomiting, anorexia, irregularity in pulse
rate and rhythm, and a sudden change in pulse.
DIF: Cognitive Level: Comprehension REF: 629 OBJ: 6
TOP: Heart Failure KEY: Nursing Process Step: Data Collection
5. Through what does an infant born with hypoplastic left heart syndrome acquire
oxygenated blood?
a. The patent ductus arteriosus
