17.7 Learning Activities

Ventricular Septal Defect (VSD) Case Study

Use the following information to answer questions 1-6.

Handoff Report:

0755: This is a 2-month-old female, Grace Thompson, admitted to the pediatric unit for evaluation and management of a known ventricular septal defect (VSD). She was born full-term with no complications, but her parents report poor feeding, rapid breathing, and excessive sweating during feeds.

Grace weighs 4.5 kg and has no known allergies. She has been exclusively breastfed but takes a long time to complete feeds and often appears fatigued.

On examination, she has a harsh holosystolic murmur at the left lower sternal border, mild intercostal retractions, and nasal flaring. Her mother states she becomes fussy and sweaty when feeding.

Vital signs:

• HR: 160 bpm
• RR: 56 breaths/min
• BP: 75/45 mmHg
• SpO₂: 96% on room air
• Weight-for-age: Below the 10th percentile

Provider Orders:

• Monitor vital signs and intake/output closely
• Daily weight
• Encourage frequent, small-volume feedings
• Supplemental oxygen PRN for SpO₂ < 92%
• Obtain chest X-ray, echocardiogram, and CBC
• Furosemide (Lasix) 0.5 mg/kg PO every 12 hours
• Enalapril 0.1 mg/kg PO twice daily
• Consult pediatric cardiology
• Discharge planning and parental education on signs of worsening heart failure

Questions

1. When reviewing Grace’s electronic health record, which assessment finding requires immediate follow-up by the nurse?

   a. Weight below the 10th percentile
   b. Harsh holosystolic murmur at the left lower sternal border
   c. Respiratory rate of 56 breaths/min with intercostal retractions
   d. Oxygen saturation of 96% on room air

2. Based on Grace’s presentation and history, which nursing diagnosis is the priority?

   a. Imbalanced nutrition: Less than body requirements related to increased energy expenditure
   b. Ineffective airway clearance related to fluid overload
   c. Risk for infection related to congenital heart defect
   d. Parental role strain related to managing a chronic condition

3. Thirty minutes after administering furosemide, the nurse notes that Grace has produced a large amount of urine and appears more fatigued. What is the nurse’s next action?

   a. Document the output and continue monitoring
   b. Check Grace’s blood pressure and electrolyte levels
   c. Stop all medications and notify the provider
   d. Offer additional breast milk or formula to compensate for fluid loss

4. The nurse is preparing to administer Enalapril to Grace. Which action demonstrates best practice?

   a. Administer the medication as scheduled without assessing vital signs
   b. Hold the medication if Grace’s blood pressure is significantly lower than baseline
   c. Crush the medication and mix it with milk for easy administration
   d. Administer the medication and document it afterward

5. What is an important teaching point for Grace’s parents before discharge?

   a. Grace should be positioned upright for feedings and given small, frequent meals
   b. They should limit Grace’s physical activity to prevent worsening symptoms
   c. Grace will likely outgrow the VSD in the next few weeks without intervention
   d. All congenital heart defects require immediate surgical correction

6. The nurse is reviewing Grace’s discharge instructions with her parents. Which statement indicates a need for further teaching?

   a. “We will watch for signs of worsening heart failure, like trouble feeding or increased sweating.”
   b. “If Grace’s breathing becomes labored, we will wait a few days to see if it improves.”
   c. “We will keep track of her weight and feedings at home.”
   d. “We’ll follow up with the pediatric cardiologist as scheduled.”