A nurse is caring for an infant experiencing a hypercyanotic, or "tet spell.”. Which interventions are appropriate for this condition?
Administer oxygen.
Encourage oral fluids.
Administer morphine.
Lay the child flat.
Place in knee-chest position.
Correct Answer : A,C,E
Choice A rationale
Hypercyanotic spells, or "tet spells," result from a sudden decrease in pulmonary blood flow and increased right-to-left shunting, leading to profound hypoxemia. Administering oxygen helps by slightly increasing arterial oxygen tension, which acts as a mild pulmonary vasodilator, potentially reducing pulmonary vascular resistance and improving oxygen delivery to tissues. This aims to counteract the immediate hypoxemia.
Choice C rationale
Morphine administration is appropriate because of its central nervous system depressant effects. It helps to calm the infant, decreasing systemic oxygen demands and reducing the hyperpnea (rapid, deep breathing) that often accompanies the spell. Furthermore, morphine mildly vasodilates, which increases systemic vascular resistance, decreasing the right-to-left shunt flow.
Choice E rationale
Placing the infant in the knee-chest position significantly increases systemic vascular resistance (SVR) by compressing the major arteries in the lower extremities. The increased SVR reduces the pressure gradient driving the right-to-left shunt through the ventricular septal defect, thereby increasing pulmonary blood flow and improving oxygen saturation during the hypercyanotic event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Elevating the head of bed (HOB) to 15-30° promotes optimal cerebral venous drainage, which assists in reducing intracranial pressure (ICP). Maintaining cerebral perfusion pressure is critical in traumatic brain injury (TBI) to prevent secondary injury from ischemia. This specific elevation angle balances ICP reduction with maintenance of adequate cerebral blood flow. Normal ICP ranges from 5-15 mmHg in children.
Choice B rationale
A quiet, low-stimulus environment minimizes external stimuli that can trigger noxious responses and subsequently increase intracranial pressure (ICP) in a child with severe TBI. Sensory input processing requires cerebral energy and can exacerbate existing cerebral edema or injury. Reducing environmental stress supports cerebral metabolic rest and neuroprotection.
Choice C rationale
Monitoring for changes in the level of consciousness (LOC) is the most sensitive indicator of neurological status and potential deterioration in a TBI patient. A declining LOC, assessed using the Glasgow Coma Scale (GCS), can signal increasing intracranial pressure (ICP) or secondary brain injury. Prompt recognition allows for timely medical or surgical intervention to preserve neurological function.
Choice D rationale
Severe TBI increases the risk for post-traumatic seizures due to focal injury, cerebral edema, or hemorrhage disrupting normal cortical electrical activity. Seizure precautions, including padding side rails and ensuring airway safety, are mandatory to prevent injury and manage potential epileptic events. Prophylactic antiepileptic medications may also be initiated based on injury severity.
Choice E rationale
Administering D5W (dextrose 5% in water) as maintenance fluid is generally contraindicated in severe TBI. This hypotonic solution can rapidly shift free water into the injured, often edematous, brain tissue, potentially worsening cerebral edema and increasing intracranial pressure (ICP). Isotonic or hypertonic solutions are preferred to maintain euvolemia and serum osmolality.
Correct Answer is ["604.8"]
Explanation
Step 1 is: Calculate the total volume of the fluid bolus in mL:. 12.6 kg × 20 mL/kg = 252 mL.
Step 2 is: Determine the time in hours for the infusion:. 25 minutes ÷ 60 minutes/hour = 0.4166. hour.
Step 3 is: Calculate the infusion rate in mL/hr:. 252 mL ÷ 0.4166. hour = 604.8 mL/hr.
Step 4 is: Round the answer to the nearest tenth:. 604.8 mL/hr. 604.8.
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