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 D

Explanation

A. While pain management is important, the priority is assessing for complications that could arise after the procedure.
B. Discharge teaching is important, but the priority immediately after the procedure is monitoring for complications.
C. While hydration is important, it is not the immediate priority following VP shunt placement, where the focus should be on assessing for signs of complications.
D. Regular monitoring of vital signs is crucial to detect complications such as shunt malfunction, infection, or increased intracranial pressure.

A. Low levels are not diagnostic B. If AFP is negative there are no genetic problems C. If AFP is high more testing is needed. D. If AFP is elevated the child will have a neural tube defect.

Correct Answer is C

Explanation

A. Low levels of AFP are not diagnostic of any condition, but they could indicate a potential issue, requiring further investigation.
B. A negative AFP test does not rule out genetic issues, as AFP is just one screening tool.
C. High levels of AFP may indicate a neural tube defect or other issues and warrant further testing, such as ultrasound or amniocentesis.
D. An elevated AFP level is associated with neural tube defects but does not definitively indicate the presence of one without further testing.

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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 caring for a child who has undergone a Ventriculoperitoneal (VP) shunt placement procedure. The nurse is aware of the need for careful prioritization of care. Which of the following actions should the nurse prioritize for this child?

Correct Answer is D

Explanation

A nurse is teaching a group of pregnant clients about health screening during pregnancy. When discussing Alpha-fetoprotein (AFP) testing, which of the following statements should be included in the education?

Correct Answer is C

Explanation

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