Assessment
Physical Indications of Cardiac Defects
Small for gestational age
Failure to thrive
Poor weight gain
Dysmorphic features
Chest wall deformities
Clubbing
Atrial Septal Defect (increased pulmonary blood flow) assessment
Heart murmur
Atrial dysrhythmias
Emboli
Respiratory infections
Poor weight gain/growth pattern
Liver enlargement
What four anatomical abnormalities does Tetraology of Fallot have?
1. ventricular septal defect
2. pulmonary stenosis
3. overriding aorta
4. right ventricular hypertrophy
Intussusception. Why is this important? What do we assess for?
Intussusception is a medical emergency where part of the intestine telescopes into itself, causing bowel obstruction. This can lead to impaired blood flow, bowel ischemia, perforation, infection (peritonitis), and shock if untreated.
Abdominal pain, often cyclical, sudden onset
Currant jelly stool
Inconsolable crying
Knees pulled up to chest
Palpable mass in some cases
Symptoms of UTIs in peds
Periorbital edema
Edema in extremities
Cloudy brown urine (cola colored)
Dysuria
Vomiting
Hypertension
Proteinuria
family history, prenatal history, birth history, developmental milestones
Atrial Septal Defects diagnostics
Enlarged right side of heart
Increased blood flow to lungs
CHF may develop
Left-to-right shunting
Assessment for TOF
Tet spells
Cyanosis with irritability and crying
Irritability due to lack of oxygen
Clubbing
Poor growth
Appendicitis. Classic signs/symptoms. What are signs of rupture?
Definition: inflammation of the vermiform appendix
Peak incidence ages 12-17 years
Common cause of peds emergency surgeries
S/S:
Abdominal Pain, right lower quad
McBurney point tenderness
Rebound tenderness
Often with fever, vomiting
Elevated wbc
Pain that is present, then absent is concerning for Rupture!
-supportive measures
-monitor I&Os and urinalysis
-prevention of complications
-monitor BP
-Na+ and fluid restrictions possible
-daily weights
-almost all children will recover
What exposure information should nurses ask when dealing with a peds cardiac patient?
infections and environmental teratogens
ASD interventions
Frequent rest periods
Monitor for CHF
Decrease work of breathing
Track growth pattern
The nurse is teaching parents of an infant with unrepaired Tetralogy of Fallot how to respond during a hypercyanotic (tet) spell at home. Which instruction should the nurse emphasize?
A) “Lay your baby flat and offer a bottle to calm them.”
B) “Hold your baby upright and encourage deep breathing.”
C) “Place your baby in a knee-chest position and call 911 if symptoms don’t improve.”
D) “Wait 10 minutes to see if your baby improves on their own before taking action.”
C) “Place your baby in a knee-chest position and call 911 if symptoms don’t improve.”
The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting and improving oxygenation during a tet spell. Immediate action is essential, and delaying intervention is unsafe. Lying flat or simply holding upright wouldn’t provide the same physiologic benefit.
What is the main symptom of a newborn with pyloric stenosis?
Projectile vomiting
What is the normal output for a child per day?
1mL/kg/hr
What physical signs does a nurse look for?
HR, respiratory status, diaphoresis, pain
ASD Management
Digoxin
Diuretics
Surgical trans-septal closure
Surgical repair
Tissue
Artificial
Kawasaki Disease Assessment
CRASH & Burn 5+ days (what does this stand for?)
Joint pain
Prolonged irritability
A 10-year-old child is admitted with suspected appendicitis. The child has right lower quadrant pain, fever, and nausea. During your assessment, the child reports sudden relief of pain and now appears pale, lying very still with shallow breathing. What is the nurse’s priority action?
A) Reassess pain in 30 minutes to confirm the change
B) Notify the provider immediately and prepare for emergency surgery
C) Offer clear fluids and continue to monitor vital signs
D) Encourage the child to ambulate to promote bowel motility
B) Notify the provider immediately and prepare for emergency surgery
Sudden relief of pain in appendicitis may indicate perforation, which is a surgical emergency. Delaying action or encouraging fluids/ambulation could worsen the situation.
What causes glomerulonephritis in children?
Glomerulonephritis is most commonly caused by an immune reaction following an infection — especially group A beta-hemolytic streptococcal infection (like strep throat or impetigo). The immune complexes deposit in the glomeruli, causing inflammation and impaired kidney function.
A nurse is assessing a 2-month-old infant with suspected congenital heart disease. Which assessment finding would most likely indicate poor cardiac output?
A) Warm, pink extremities with brisk capillary refill
B) Cool extremities with capillary refill greater than 4 seconds
C) Heart rate of 120 beats per minute
D) Mild tachypnea without retractions
B) Cool extremities with capillary refill greater than 4 seconds
Poor perfusion indicated by cool extremities and delayed capillary refill suggests compromised cardiac output requiring urgent intervention.
A nurse is assessing a 6-month-old infant with an unrepaired atrial septal defect. The infant’s parent reports frequent respiratory infections and poor feeding. On exam, the nurse notes a heart murmur, mild hepatomegaly, and tachypnea with mild retractions. What is the nurse’s best next action?
A) Document findings and plan routine follow-up with cardiology
B) Provide oxygen as needed and notify the provider about possible congestive heart failure
C) Encourage the parent to offer larger, less frequent feedings to conserve energy
D) Reassure the parent that these are expected findings with an ASD
B) Provide oxygen as needed and notify the provider about possible congestive heart failure
The combination of poor feeding, frequent infections, hepatomegaly, tachypnea, and retractions suggests that the ASD may be leading to congestive heart failure (CHF). Oxygen support and prompt provider notification are priorities. Larger feedings would increase work of breathing, and these findings are concerning, not expected to be ignored.
A nurse is caring for a 2-year-old hospitalized with the acute phase of Kawasaki disease. The child has a high fever, red cracked lips, swollen hands, and irritability. What is the nurse’s priority action at this time?
A) Apply cool compresses to the hands to reduce swelling
B) Administer the ordered IV immunoglobulin (IVIG) and aspirin as scheduled
C) Encourage the child to walk around the room to reduce joint stiffness
D) Delay medications until the fever subsides naturally
B) Administer the ordered IV immunoglobulin (IVIG) and aspirin as scheduled
The priority is to begin treatment with IVIG and high-dose aspirin to reduce inflammation and lower the risk of coronary artery aneurysms. Cool compresses may help comfort but are not the priority. Early mobilization is not appropriate until the child is stable, and medications should not be delayed because fever is part of the disease process.
A 5-week-old infant diagnosed with pyloric stenosis is admitted for surgery. The nurse notes the infant is lethargic and has dry mucous membranes, decreased urine output, and a history of frequent projectile vomiting. What is the nurse’s priority nursing intervention before surgery?
A) Initiate IV fluids to correct dehydration and electrolyte imbalances
B) Encourage oral rehydration with small frequent feeds
C) Prepare the infant for immediate surgery without delay
D) Administer antiemetic medications as ordered
A) Initiate IV fluids to correct dehydration and electrolyte imbalances
Infants with pyloric stenosis are often dehydrated and have metabolic imbalances due to vomiting. Correcting these imbalances with IV fluids is essential before surgery to reduce perioperative risk. Oral feeds may worsen vomiting; antiemetics are less commonly used, and surgery should be delayed until the infant is stabilized.
A nurse is assessing a 6-month-old infant with a suspected urinary tract infection (UTI). Which finding should the nurse recognize as most consistent with a UTI in this age group?
A) Frequent urination with burning on urination
B) Fever, irritability, and poor feeding
C) Flank pain and costovertebral angle tenderness
D) Dysuria and urgency
B) Fever, irritability, and poor feeding
Infants often present with nonspecific signs such as fever, irritability, vomiting, diarrhea, and poor feeding rather than the classic dysuria or frequency seen in older children. Flank pain and CVA tenderness are more common in pyelonephritis in older children.