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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Correct Answer is B
Explanation
Prepare for emergency surgery.
Choice A rationale:
Administer oxygen therapy immediately.
Administering oxygen therapy would provide temporary relief to the patient's cyanosis, but it does not address the underlying issue in Tetralogy of Fallot (TOF).
TOF is a congenital heart defect characterized by a combination of four heart abnormalities, one of which is a ventricular septal defect (VSD) that allows oxygen-poor blood to mix with oxygen-rich blood.
Administering oxygen will increase the oxygen saturation in the blood but will not fix the structural problem.
The immediate priority for a patient with TOF experiencing a hypercyanotic spell is to address the heart defect itself.
Choice B rationale:
Prepare for emergency surgery.
In Tetralogy of Fallot, hypercyanotic spells, also known as "tet spells," are a medical emergency.
These spells occur due to a sudden decrease in systemic vascular resistance, causing more blood to flow into the right ventricle, leading to increased right-to-left shunting, further decreasing oxygenation.
The most appropriate intervention is to prepare for emergency surgery to correct the underlying cardiac defects, such as closing the VSD and relieving right ventricular outflow obstruction.
Surgery is the definitive treatment for TOF and should be performed promptly during a tet spell to prevent severe hypoxia and potential long-term complications.
Choice C rationale:
Monitor vital signs closely.
While monitoring vital signs is essential in the care of a patient with TOF, it is not the most immediate response in the scenario of a hypercyanotic spell.
Monitoring alone will not address the critical need for intervention to improve oxygenation and prevent hypoxia.
Choice D rationale:
Administer prescribed medication.
Administering prescribed medication may be part of the overall management of a patient with TOF, but it is not the immediate response during a hypercyanotic spell.
Medications can help manage symptoms and stabilize the patient, but the definitive treatment for TOF is surgical correction.
Correct Answer is B
Explanation
"Long-term monitoring will include regular follow-up appointments with the cardiologist.”.
Choice A rationale:
Stating, "It's essential to schedule cardiac rehabilitation sessions for your child," is not accurate for the long-term management of a congenital heart defect.
Cardiac rehabilitation is typically recommended for individuals who have experienced a cardiac event, such as a heart attack, but it is not a standard part of the long-term management of congenital heart defects in children.
Choice B rationale:
Informing the client that long-term monitoring will include regular follow-up appointments with the cardiologist is The correct nursing response.
Regular follow-up appointments are essential for monitoring the child's heart condition, adjusting treatment as needed, and ensuring their overall well-being.
This choice is accurate and aligned with best practices.
Choice C rationale:
Stating, "You can discontinue all medications once your child reaches a certain age," is not accurate or safe advice.
The need for medications in the management of a congenital heart defect is determined by the child's specific condition and the recommendations of the healthcare team.
Discontinuing medications without medical guidance can be dangerous and is not a standard practice.
Choice D rationale:
Claiming, "Balloon valvuloplasty will be the primary treatment for long-term management," is not a universally applicable statement.
The choice of treatment for long-term management of a congenital heart defect depends on the specific diagnosis and clinical circumstances.
While balloon valvuloplasty may be a suitable treatment in some cases, it is not the primary treatment for all congenital heart defects.
Individualized care plans are developed based on the child's condition.
Therefore, this statement is not accurate as a general rule.
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