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 D

Explanation

A. "Place your baby in a side-lying position when sleeping." The recommended sleep position for infants is on their back to reduce the risk of sudden infant death syndrome (SIDS).
B. "Use a drop-side crib until your baby is at least 6 months old." Drop-side cribs are not recommended due to the risk of injury or suffocation; they have been banned in many regions.
C. "Apply a plastic mattress cover to your baby's bed to protect it." Plastic mattress covers increase the risk of suffocation and are not recommended.
D. "Keep your infant restrained when they are in a highchair." Proper restraints prevent falls or injuries when the infant is seated in a highchair.

A. Maintain NPO status. B. Administer an antipyretic. C. Initiate an infusion of IV fluids. D. Administer a cleansing enema. E. Prepare child and parents for ostomy placement. F. Educate child and parents about plan of care. G. Administer an analgesic. H. Administer antibiotics.

Correct Answer is ["A","B","C","F","G","H"]

Explanation

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

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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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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a group of guardians of infants about home safety. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","F","G","H"]

Explanation

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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.