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 A
Explanation
A. Lime ice pop: A lime ice pop is a good option because it is cold, soothing, and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort. Additionally, it is not acidic or dairy-based, which makes it a safe choice.
B. Cranberry juice: Cranberry juice is acidic, which can irritate the throat and increase discomfort after a tonsillectomy. Acidic foods and drinks should be avoided during the recovery period to prevent irritation and pain.
C. Ice cream: While ice cream is cold and soothing, it contains dairy, which can increase mucus production. This may lead to discomfort and make swallowing more difficult post-surgery. It’s best to avoid dairy products immediately following a tonsillectomy.
D. Hot tea : Hot beverages should be avoided because they can cause vasodilation and increase the risk of postoperative bleeding. Cold or room temperature liquids are preferred to minimize discomfort and prevent complications.
Correct Answer is C
Explanation
A. "SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines." This statement is incorrect and misleading. There is no direct correlation between SIDS and vaccinations like the diphtheria, tetanus, and pertussis (DTP) vaccines. In fact, immunizations are an important part of a child's health and can help prevent diseases that could lead to complications, including those that might be indirectly related to SIDS risk factors.
B. "SIDS rates have been rising over the last 10 years." This statement is false. SIDS rates have generally been decreasing, especially since the introduction of public health campaigns promoting safe sleep practices, such as placing infants on their backs to sleep.
C. "You should place your baby on her back when sleeping to decrease the risk of SIDS." This is the correct and evidence-based recommendation. Placing a baby on their back to sleep significantly reduces the risk of SIDS. This practice is part of the "Back to Sleep" campaign, which has been shown to lower the incidence of SIDS.
D. "Sleep apnea is the main cause of SIDS." This statement is incorrect. While sleep apnea has been studied as a potential risk factor, it is not considered the main cause of SIDS. The exact cause of SIDS is still unknown, but it is believed to be related to multiple factors, including sleep environment and infant physiology.
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