A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect?

Select all that apply.

Bounding peripheral pulses

Cyanotic spells

Stridor

Anemia

heart murmur

Answer and Explanation

Correct Answer : B,E

A. "Bounding peripheral pulses." Bounding pulses are not characteristic of Tetralogy of Fallot. Instead, pulses may be normal or diminished, depending on the severity of the defect.
B. "Cyanotic spells." Tetralogy of Fallot causes decreased oxygenation, leading to periodic cyanotic episodes, particularly during crying or feeding ("tet spells").
C. "Stridor." Stridor is associated with upper airway obstructions, not cardiac defects like Tetralogy of Fallot.
D. "Anemia." Anemia is not a primary finding in Tetralogy of Fallot. Polycythemia (increased red blood cells) is more common due to chronic hypoxia.
E. "Heart murmur." A systolic murmur is common due to the pulmonary stenosis and ventricular septal defect associated with Tetralogy of Fallot.

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Correct Answer is A

Explanation

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

A. Superficial scrapes on the toddler's lower legs B. Circular burns on the soles of the toddler's feet C. Irregular area of blue pigmentation over the toddler's sacrum D. Single bruise on the toddler's forearm

Correct Answer is B

Explanation

A. Superficial scrapes on the toddler's lower legs: These are common in toddlers due to normal play and exploration.
B. Circular burns on the soles of the toddler's feet: Circular burns, especially in unusual areas like the soles, are a hallmark sign of intentional injury and potential abuse.
C. Irregular area of blue pigmentation over the sacrum: This is likely a Mongolian spot, a benign and common finding in children of certain ethnicities.
D. Single bruise on the toddler's forearm: This is not necessarily indicative of abuse, as toddlers frequently sustain minor injuries from routine activities.

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A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect? Select all that apply.

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A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect?

Select all that apply.