A nurse is assisting in the care of an infant who has congenital heart disease.
Place the infant in a knee chest position
Administer morphine via IV bolus
Provide 100% oxygen by face mask
Request a prescription for a diuretic
Perform nasopharyngeal suctioning for a maximum of 5 seconds
Prepare to assist with the insertion of a chest tube
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Place the infant in a knee-chest position: Indicated: ☑️
The knee-chest position is commonly used during a "tet spell," which involves episodes of cyanosis due to decreased oxygen levels. This position increases systemic vascular resistance, which helps redirect blood flow to the lungs, improving oxygenation.
Administer morphine via IV bolus: Indicated: ☑️
Morphine is used to calm the infant, reduce respiratory effort, and decrease pulmonary vascular resistance. It can help in reducing the severity of the tet spell by promoting better oxygenation.
Provide 100% oxygen by face mask: Indicated: ☑️
Administering 100% oxygen can help increase the amount of oxygen in the blood and reduce the effects of hypoxia. Oxygen is a vasodilator and can reduce pulmonary resistance, making it easier for the infant to oxygenate blood.
Request a prescription for a diuretic: Contraindicated: ☑️
Diuretics are generally not indicated in the acute management of tet spells. While they are used in conditions with fluid overload, their use in this context is not beneficial and could potentially worsen the infant's condition by causing dehydration and further reducing blood volume.
Perform nasopharyngeal suctioning for a maximum of 5 seconds: Contraindicated: ☑️
Nasopharyngeal suctioning can be stressful for the infant and may worsen cyanosis or provoke a tet spell due to increased agitation and respiratory effort. It's typically not recommended unless there's a clear indication for airway clearance.
Prepare to assist with the insertion of a chest tube: Contraindicated: ☑️
Chest tube insertion is not a treatment for tet spells or ToF. It is usually indicated for pneumothorax or significant pleural effusions, which are not related to the acute cyanotic episodes seen in ToF. Preparing for this procedure would be inappropriate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Absent plantar reflexes: This is not typically associated with DDH. DDH affects the hip joint's formation, not reflexes.
B. Inwardly turned foot on the affected side: This finding is more indicative of conditions like clubfoot, not DDH.
C. Asymmetric thigh folds: This is a common finding in DDH. The folds may appear uneven due to the displacement of the femoral head.
D. Lengthened thigh on the affected side: In DDH, the thigh on the affected side may actually appear shorter, not longer, due to hip dislocation.
Correct Answer is C
Explanation
A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.
B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.
C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.
D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.
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