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Nursing Care Plan

Chapter 41: Nursing Care of the Child With a Cardiovascular Disorder

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1. Baby boy Ellis, 2 hours old, is being evaluated in the newborn nursery by the nursing staff. Findings include T 37°C; apical heart rate 140 bpm; respirations 58 breaths per minute; BP (arms) 70/47, (calves) 62/39; head circumference 34 cm; chest circumference 31 cm; length 48 cm; weight 2,700 g. The infant is crying. (Learning Objectives 1, 2, 3, 4, and 8)

a. Based on the physical findings, what should be the nurse’s priority?

b. What assessments/tests should the nurse expect to be done on this infant?

c. What should the nurse include in the teaching plan for the parents of this infant?

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2. Jennifer Collins, 13 years old, is admitted to the pediatric floor with a diagnosis of probable acute rheumatic fever.

a. What would the nurse include when performing an initial assessment?

b. What tests would the nurse expect to be done on Jennifer?

The diagnosis of acute rheumatic fever is confirmed.

c. What would the nurse be sure to include in the discharge teaching plan for Jennifer and her family?

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