The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?

Correct Answer: D

Rationale: If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.

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: B

Rationale: In pediatric cardiovascular nursing, understanding the rationale behind dietary recommendations for children on specific medications like furosemide (Lasix) is crucial. The correct answer is option B) Potassium. Explanation of why Potassium is right: Furosemide is a loop diuretic that promotes the excretion of water and electrolytes, including potassium. Potassium depletion can be a side effect of furosemide use. Therefore, it is essential to consume potassium-rich foods like bananas, oranges, and leafy vegetables to replenish potassium levels and prevent hypokalemia, which can lead to adverse cardiac effects. Explanation of why others are wrong: A) Chlorides: While furosemide may affect chloride levels, the primary concern with furosemide use in this context is potassium depletion. C) Sodium: Furosemide actually promotes the excretion of sodium, so increasing sodium intake would not address the potential electrolyte imbalance caused by the medication. D) Vitamins: While vitamins are essential for overall health, the specific concern with furosemide use in this case is potassium depletion, not vitamin deficiency. Educational context: Educating families on the importance of potassium-rich foods when a child is taking furosemide helps ensure optimal medication effectiveness and reduces the risk of adverse effects. Understanding the rationale behind dietary recommendations empowers caregivers to actively participate in their child's care and promotes better outcomes in pediatric cardiovascular management.

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