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 ["A","C","D"]

Explanation

A. Right atrial enlargement occurs due to the increased blood flow from left to right shunting, which can cause volume overload in the right atrium.
B. Left atrial enlargement is typically seen in conditions that cause increased left atrial pressure, such as mitral valve disease or left-sided heart failure, not in ASD.
C. Shortness of breath is a common symptom due to increased blood flow to the lungs, which can lead to pulmonary congestion.
D. Pulmonary hypertension may develop over time due to increased blood flow and pressure in the pulmonary circulation from the left-to-right shunting of blood.
E. Pulmonary hypotension is not associated with ASD. The condition typically leads to increased pressure in the pulmonary arteries, not decreased pressure

A. Elevating the legs on a pillow B. Applying heat therapy to the casted area C. Removing the casts periodically for bathing D. Encouraging the infant to crawl and bear weight on the affected leg

Correct Answer is A

Explanation

A. Elevating the legs on a pillow helps reduce swelling and discomfort while the cast is healing.
B. Heat therapy should not be applied to the casted area, as it could cause skin irritation or burns.
C. Casts should not be removed for bathing unless specifically ordered by the provider.
D. Encouraging the infant to crawl or bear weight on the affected leg is not appropriate until the cast is removed and healing is complete.

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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

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