A nurse caring for a child with a congenital heart defect is performing a physical examination.
Which statement reflects an appropriate action during the assessment?
"I will check the child's oxygen saturation using a pulse oximeter.”
"I'll ensure the child receives all their vaccinations today.”
"I'll assess the child's neurological development.”
"I will monitor the child's growth based on height alone.”
The Correct Answer is A
Choice A rationale:
Checking the child's oxygen saturation using a pulse oximeter is an appropriate action during the assessment of a child with a congenital heart defect.
Oxygen saturation monitoring helps assess the child's oxygen levels, which is crucial in determining the adequacy of oxygen supply to the body.
Children with congenital heart defects are at risk of reduced oxygen levels, and monitoring oxygen saturation is a vital part of their care.
Choice B rationale:
Ensuring the child receives all their vaccinations is important for the child's overall health but is not directly related to the assessment of a congenital heart defect.
Vaccinations are typically administered as part of routine healthcare, but they do not address the specific concerns related to a congenital heart defect assessment.
Choice C rationale:
Assessing the child's neurological development is important but is not the primary focus of the assessment for a congenital heart defect.
While neurological assessment is important for overall child development, it does not directly relate to the cardiac assessment.
Choice D rationale:
Monitoring the child's growth based on height alone is not a comprehensive assessment for a child with a congenital heart defect.
Monitoring growth should include various parameters, such as weight, head circumference, and developmental milestones.
Relying solely on height may not provide a complete picture of the child's overall development.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's response should include teaching proper positioning techniques as optimizing a child's respiratory function can be improved by correct positioning.
Proper positioning helps ensure that the child's airways are open and not obstructed, which is essential for effective breathing.
This is a fundamental aspect of respiratory care, especially in pediatric patients who may not be able to reposition themselves if they are uncomfortable or experiencing difficulty breathing.
Choice B rationale:
Administering vasodilators is not typically a measure to optimize a child's respiratory function.
Vasodilators are medications that dilate blood vessels and are usually used in specific cardiovascular conditions to reduce the workload on the heart.
They are not directly related to optimizing respiratory function.
Choice C rationale:
Monitoring growth patterns, while important for a child's overall health, is not a direct response to the client's question about optimizing respiratory function.
Growth patterns are assessed for general development and health, but they do not specifically address respiratory function.
Choice D rationale:
Providing information on the child's condition is essential, but it does not directly address the question about optimizing respiratory function.
While education is crucial, the primary focus should be on practical measures to improve the child's respiratory function, such as proper positioning and breathing techniques.
Correct Answer is A
Explanation
Choice A rationale:
Cyanosis that worsens with crying or feeding is characteristic of Tetralogy of Fallot (TOF).
TOF is a congenital heart defect characterized by four specific cardiac abnormalities, one of which is a ventricular septal defect (VSD).
The VSD allows deoxygenated blood to flow from the right ventricle into the left ventricle and then into the aorta, leading to systemic cyanosis, which is exacerbated by crying or feeding due to increased right-to-left shunting.
Choice B rationale:
Severe chest pain is not a characteristic symptom of Tetralogy of Fallot (TOF).
TOF primarily presents with cyanosis and other associated symptoms related to the heart defect.
Choice C rationale:
Palpitations are not a characteristic symptom of TOF.
While some children with congenital heart defects may experience palpitations, this is not a specific hallmark of TOF.
Choice D rationale:
Frequent respiratory infections are not a characteristic symptom of TOF.
The symptoms associated with TOF are primarily related to cardiac function, such as cyanosis, and do not directly cause respiratory infections.
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