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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Non-contact sports like swimming are generally safe for children with hemophilia as they carry a lower risk of injury.
B. Wearing helmets and protective gear is an important safety measure for children with hemophilia to prevent trauma.
C. While it is important to avoid excessive risk of injury, children with hemophilia can still participate in many activities with precautions.
D. NSAIDs should not be used in children with hemophilia as they can increase the risk of bleeding. Acetaminophen (Tylenol) is a safer option for pain relief.
Correct Answer is ["B","D","E"]
Explanation
A. Swelling in all extremities is not typically a symptom of VSD; it may indicate a different cardiac or renal issue.
B. Frequent lung infections are common in children with VSD due to pulmonary congestion.
C. Standard weight and growth percentile is not typical for VSD, as the child may experience failure to thrive.
D. Dyspnea occurs due to increased blood flow to the lungs and pulmonary congestion.
E. A heart murmur is a hallmark of VSD, heard due to the abnormal flow of blood through the septal defect.
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