A 3-year-old child is diagnosed with congenital heart disease (CHD), specifically tetralogy of Fallot. The nurse is preparing to assess the child's cardiac status. Which of the following clinical manifestations is most commonly seen in children with tetralogy of Fallot?
Barking cough and inspiratory stridor, especially at night
Bradycardia and hypotension following minor activity or mild stress
Cyanosis that worsens during crying or feeding, often relieved by squatting
Peripheral edema and hepatomegaly during exertion or prolonged play
The Correct Answer is C
A. Barking cough and inspiratory stridor, especially at night is incorrect because this is characteristic of croup, a respiratory condition, not tetralogy of Fallot. Tetralogy of Fallot primarily affects cardiac blood flow, not the upper airway.
B. Bradycardia and hypotension following minor activity or mild stress is incorrect because children with tetralogy of Fallot typically develop tachycardia in response to hypoxia or stress, rather than bradycardia. Hypotension is not a hallmark sign unless there is shock or severe complications.
C. Cyanosis that worsens during crying or feeding, often relieved by squatting is correct because children with tetralogy of Fallot have right-to-left shunting due to the combination of ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. This shunting reduces pulmonary blood flow, leading to cyanosis, which often becomes more pronounced during periods of increased oxygen demand, such as crying or feeding. Squatting increases systemic vascular resistance, temporarily reducing the shunt and improving oxygenation, which is known as a “Tet spell” relief maneuver.
D. Peripheral edema and hepatomegaly during exertion or prolonged play is incorrect because these signs are more typical of heart failure rather than tetralogy of Fallot in a child without chronic severe heart failure. Tetralogy of Fallot presents primarily with cyanosis and hypoxic spells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Limiting family involvement to scheduled visiting hours is incorrect because family-centered care promotes unrestricted or flexible family presence. Restricting involvement contradicts the idea that the family plays a continuous and central role in the child’s life.
B. Encouraging the family to follow unit routines without modification is incorrect because family-centered care values collaboration and flexibility. Care should be adapted to meet the needs of the child and family, not force the family to conform to rigid hospital routines.
C. Assuming the healthcare team is the primary source of support for the child is incorrect because, in family-centered care, the family—not the healthcare team—is recognized as the primary and constant source of support, comfort, and advocacy for the child.
D. Involving the family in care planning and decision-making for the child is correct because it acknowledges that the family is the constant in the child’s life. This approach respects the family’s knowledge of the child, promotes collaboration, and supports continuity of care across healthcare settings.
Correct Answer is D
Explanation
A. Patent ductus arteriosus, foramen ovale, aortic arch is incorrect because the aortic arch is a normal part of the circulatory system and does not close after birth. A patent ductus arteriosus is abnormal if it remains open after birth.
B. Foramen ovale, ductus arteriosus, coronary sinus is incorrect because the coronary sinus is a normal cardiac structure that collects venous blood from the myocardium into the right atrium; it does not close after birth.
C. Pulmonary artery, ductus venosus, tricuspid valve is incorrect because the pulmonary artery and tricuspid valve are normal heart structures, not fetal shunts. Only the ductus venosus among these closes after birth.
D. Foramen ovale, ductus arteriosus, ductus venosus is correct because these three fetal shunts bypass the lungs and liver: the foramen ovale allows blood to flow from the right atrium to the left atrium, bypassing the lungs; the ductus arteriosus connects the pulmonary artery to the aorta, diverting blood from the lungs; and the ductus venosus shunts oxygenated blood from the umbilical vein directly to the inferior vena cava, bypassing the liver. These structures normally close after birth as the newborn transitions to pulmonary and hepatic circulation.
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