An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.

Correct Answer: B

Rationale: In pediatric cardiovascular nursing, monitoring a child's response to digoxin therapy is crucial due to its narrow therapeutic index and potential toxicity. The correct answer is option B) 70 beats/min. This is because digoxin, a cardiac glycoside, works by increasing the force of the heart's contractions, but with toxicity, it can lead to bradycardia. An apical pulse below 70 beats/min in a child indicates bradycardia, which can be a sign of digoxin toxicity. Option A) 60 beats/min is too low for a child's normal pulse rate and would indicate a need for intervention or further assessment, but it is not the specific threshold for digoxin toxicity. Option C) 90 and D) 100 beats/min are within normal pediatric pulse ranges and would not necessarily indicate digoxin toxicity. Educationally, understanding the impact of digoxin on the pediatric cardiovascular system, the importance of monitoring vital signs, especially the pulse rate, and recognizing signs of toxicity are vital for nurses caring for pediatric patients on digoxin therapy. This knowledge ensures early detection of adverse effects, prompt intervention, and improved patient outcomes.

Correct Answer: D

Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.

Correct Answer: A

Rationale: Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous odules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis

Correct Answer: C

Rationale: Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A β-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A β-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

Correct Answer: D

Rationale: Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.