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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Clear bilateral breath sounds are not typical in PDA; instead, crackles or signs of respiratory distress may be present.
B. Dyspnea (difficulty breathing) is common due to the increased pulmonary blood flow from the PDA.
C. A machine-like murmur heard at the right upper sternal border is characteristic of PDA.
D. Cyanosis is typically not present in isolated PDA unless the PDA is large and leads to right-to-left shunting.
E. Difficulty feeding is a common symptom because the newborn may tire easily due to inefficient circulation and increased work of breathing.

A. Dress the child in woolen clothes during cold months. B. Encourage the parent to bathe the child daily with hot water and mild soap to keep the skin clean. C. Instruct the parent to dress the child in loose-fitting cotton clothing to help prevent irritation. D. Suggest to the parent to avoid using any moisturizers on the child's skin to prevent further irritation.

Correct Answer is C

Explanation

A. Woolen clothes may irritate the skin and should be avoided by children with eczema.
B. Hot water and frequent baths can dry out and irritate the skin, worsening eczema. Lukewarm water is recommended.
C. Loose cotton clothing helps to minimize irritation and sweating, which can worsen eczema symptoms.
D. Moisturizers are essential for managing eczema and preventing skin dryness. They should be used regularly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is caring for a newborn with suspected Patent Ductus Arteriosus (PDA). What signs and symptoms should the nurse expect to find when assessing the newborn? (Select All That Apply).

Correct Answer is ["B","C","E"]

Explanation

A nurse is providing teaching to a parent of a preschooler client who has eczema. Which of the following Instructions should the nurse include In the teaching?

Correct Answer is C

Explanation

A school nurse is providing teaching to an adolescent client about the management of acne. Which of the following should the nurse include in the Instructions?

A nurse is caring for a 13-year-old with a tibia, fibula fracture, what is the priority assessment after a cast has been applied?

A nurse is providing care for an infant with new casts for the treatment of club foot. Which intervention is appropriate in promoting the infant's comfort and preventing complications?

A nurse is caring for a child with a diagnosis of Duchenne's muscular dystrophy (DMD). The nurse should recognize that which of the following accurately describes Duchenne muscular dystrophy (DMD)? (Select All that Apply.)

A nurse is assessing a 5-month-old Infant who has had a seizure and high pitched crying with a high fever. The nurse anticipates the need for which diagnostic testing?

A nurse is caring for an infant post operative closure of a myelomeningocele. Which intervention is essential for providing basic care and comfort following myelomeningocele sac closure?

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?