A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Administer morphine sulfate to help alleviate pain and anxiety.

Provide supplemental oxygen via nasal cannula.

Offer the infant a pacifier to calm down.

Place the infant in a knee to chest position.

Answer and Explanation

The Correct Answer is D

A.   While morphine can help to relieve anxiety and pain, it does not address the underlying cause of a hypercyanotic spell, which is the right-to-left shunting. The first step should be positioning the infant properly.
B.   Although oxygen is helpful, it will not be as effective as using the knee-to-chest position to alleviate the underlying circulatory issue causing the hypercyanotic spell.
C.   While comforting the child is important, a pacifier will not help in alleviating the hypercyanotic spell and is not the primary intervention in this emergency situation.
D.   In a hypercyanotic spell, the priority is to increase systemic vascular resistance to decrease the right- to-left shunting of blood. The knee-to-chest position is effective for this, as it increases the resistance in the lower extremities, helping to improve oxygenation.

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Correct Answer is B

Explanation

A. Chelation therapy does not stimulate hemoglobin production; it primarily targets iron overload, which can occur due to repeated transfusions.
B. Chelation therapy helps remove excess iron from the body, which accumulates due to frequent blood transfusions required in children with thalassemia.
C. Chelation therapy does not stimulate RBC production. It addresses the issue of iron overload.
D. Chelation therapy does not prevent infections. It is specifically used to treat iron overload in thalassemia patients.

A. Complete blood count B. Urinalysis C. Abdominal ultrasound D. Bladder scan

Correct Answer is B

Explanation

A complete blood count (CBC) may be ordered later if further infection or sepsis is suspected, but it is not the first diagnostic test.
B. Urinalysis is the most appropriate initial test to diagnose a urinary tract infection (UTI), which is common in children with symptoms such as dysuria and irritability.
C. An abdominal ultrasound is more appropriate if there are concerns about abdominal pathology, which is not suggested by the symptoms.
D. A bladder scan is not the first diagnostic step and would be used to assess post-void residual urine if necessary.

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A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly diagnosed client about B-thalassemla major (Cooley anemla). What response by the client indicates correct understanding of Chelation therapy?

Correct Answer is B

Explanation

A 2-year-old child presents to the hospital with a fever of 38.4 Celsius and the parents state the child has had dysuria and Irritability, with a loss of appetite. What diagnostic test should the nurse expect to be ordered first based on the symptoms?

Correct Answer is B

Explanation

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