A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?

Choice A rationale
While gastrointestinal symptoms can occur in Kawasaki disease, such as diarrhea, vomiting, and abdominal pain, the primary system affected is not the gastrointestinal system.
Choice B rationale
Although Kawasaki disease can cause symptoms such as a rash and changes in the lips and oral cavity, which are related to the integumentary system, the primary system affected is not the integumentary system.
Choice C rationale
Respiratory symptoms are not typically a primary concern in Kawasaki disease. While a child with Kawasaki disease may have some respiratory symptoms such as a cough and runny nose, these are not the main focus of monitoring.
Choice D rationale
Kawasaki disease is a systemic vasculitis that predominantly affects the cardiovascular system. It is the leading cause of acquired heart disease in children. Therefore, monitoring the cardiovascular system is crucial in managing a child with Kawasaki disease.

Choice A rationale
Tetralogy of Fallot is a congenital heart defect that includes four specific heart abnormalities: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.
Choice B rationale
This choice incorrectly identifies aortic stenosis and atrial septal defect as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and a ventricular septal defect.
Choice C rationale
This choice incorrectly identifies pulmonary stenosis and aortic hypertrophy as components of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis and right ventricular hypertrophy.
Choice D rationale
This choice incorrectly identifies aortic stenosis as a component of Tetralogy of Fallot. In fact, the condition involves pulmonic stenosis.