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. 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.

A. No venipuncture or blood pressure in either arm. B. Avoid administering nephrotoxic medications. C. Collect all urine. D. Strict fluid restrictions.

Correct Answer is A

Explanation

A. Wilms' tumor is a kidney tumor, and the child should not have blood pressure measured or venipuncture done on the affected side to avoid any potential injury to the kidney.
B. This is important in care but is not the primary immediate precaution. The main focus is to avoid injury to the affected kidney.
C. While urine collection is important for monitoring kidney function, it is not a warning sign for Wilms' tumor.
D. This may be necessary later in the treatment but is not a primary concern for the initial care of a child with Wilms' tumor.

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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 parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent Indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is admitting a child with a suspected diagnosis of Wilm's tumor. The nurse should place a sign with which of the following warnings about this child?

Correct Answer is A

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?

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect?

A child with leukemia is receiving intrathecal chemotherapy. The nurse should recognize that intrathecal chemotherapy will prevent which of the following?

A nurse is caring for a client who has a defect that allows blood flow from the left side to the right side of the heart through an abnormal connection. Which of the following defect results in increased pulmonary blood flow?

A nurse is caring for a preschool client who has Tetralogy of Fallot (TOF). What are the defects the nurse should be aware of when caring for a client with Teratology of Fallot (TOF)? (Select all that apply).

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?

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).