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Chapter 19: Nursing Care of the Child With
an Alteration in Perfusion/Cardiovascular
Disorder Verified and Updated Questions
and Answers (100% Correct Answers)
1. The nurse is conducting a physical examination of a child with a ventricular septal
defect. Which finding would the nurse expect to assess?
A) Right ventricular heave
B) Holosystolic harsh murmur along the left sternal border
C) Fixed split-second heart sound
D) Systolic ejection murmur
Answer: Ans: B
Feedback: With ventricular septal defects, there is often a characteristic holosystolic
harsh murmur along the left sternal border. Right ventricular heave, fixed split-
second heart sound, and systolic ejection murmur are typically found with atrial
septal defects
2. The nurse is administering digoxin as ordered and the child vomits the dose. What
should the nurse do next?
A) Contact the physician.
B) Offer a snack and administer another dose.
C) Immediately administer another dose.
D) Administer next dose as ordered in 12 hours.
Answer: Ans: D
Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1
hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should
not give a second dose and should wait until the next scheduled dose. It is not
necessary to contact the physician.
, Inquire through: | Professional | Confidential Support
3. The nurse is caring for an infant with suspected patent ductus arteriosus. Which
assessment finding would the nurse identify as helping to confirm this suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border
Answer: Ans: B
Feedback: With patent ductus arteriosus, a harsh, continuous, machine-like murmur
(usually loudest under the left clavicle) is heard at the first and second intercostal
spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the
left sternal border point to aortic stenosis.
4. The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess
if the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling pressure
C) Soft systolic ejection
D) Holosystolic murmur
Answer: Ans: A
Feedback: Significant cyanosis without presence of a murmur is highly indicative of
transposition. Abrupt cessation of chest output accompanied by an increase in heart
rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection
or holosystolic murmur can be found with other disorders, such as hypoplastic left
heart syndrome, but is not highly suspicious of transposition.
5. The nurse is assessing a child with suspected infective endocarditis. Which
assessment finding would the nurse interpret as a sign of extracardiac emboli?
A) Pruritus
B) Roth spots
Chapter 19: Nursing Care of the Child With
an Alteration in Perfusion/Cardiovascular
Disorder Verified and Updated Questions
and Answers (100% Correct Answers)
1. The nurse is conducting a physical examination of a child with a ventricular septal
defect. Which finding would the nurse expect to assess?
A) Right ventricular heave
B) Holosystolic harsh murmur along the left sternal border
C) Fixed split-second heart sound
D) Systolic ejection murmur
Answer: Ans: B
Feedback: With ventricular septal defects, there is often a characteristic holosystolic
harsh murmur along the left sternal border. Right ventricular heave, fixed split-
second heart sound, and systolic ejection murmur are typically found with atrial
septal defects
2. The nurse is administering digoxin as ordered and the child vomits the dose. What
should the nurse do next?
A) Contact the physician.
B) Offer a snack and administer another dose.
C) Immediately administer another dose.
D) Administer next dose as ordered in 12 hours.
Answer: Ans: D
Feedback: Digoxin should be administered at regular intervals, every 12 hours, 1
hour before or 2 hours after feeding. If the child vomits digoxin, the nurse should
not give a second dose and should wait until the next scheduled dose. It is not
necessary to contact the physician.
, Inquire through: | Professional | Confidential Support
3. The nurse is caring for an infant with suspected patent ductus arteriosus. Which
assessment finding would the nurse identify as helping to confirm this suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border
Answer: Ans: B
Feedback: With patent ductus arteriosus, a harsh, continuous, machine-like murmur
(usually loudest under the left clavicle) is heard at the first and second intercostal
spaces. A thrill at the base, faint pulses, and systolic murmur heard best along the
left sternal border point to aortic stenosis.
4. The nurse is conducting a physical examination of a child with a suspected
cardiovascular disorder. Which finding would the nurse most likely expect to assess
if the child had transposition of the great vessels?
A) Significant cyanosis without presence of a murmur
B) Abrupt cessation of chest output with an increase in heart rate/filling pressure
C) Soft systolic ejection
D) Holosystolic murmur
Answer: Ans: A
Feedback: Significant cyanosis without presence of a murmur is highly indicative of
transposition. Abrupt cessation of chest output accompanied by an increase in heart
rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection
or holosystolic murmur can be found with other disorders, such as hypoplastic left
heart syndrome, but is not highly suspicious of transposition.
5. The nurse is assessing a child with suspected infective endocarditis. Which
assessment finding would the nurse interpret as a sign of extracardiac emboli?
A) Pruritus
B) Roth spots
