A nurse is caring for an infant who has congenital heart disease.
Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)
Administer morphine via IV bolus.
Prepare to assist with the insertion of a chest tube.
Place the infant in a knee-chest position.
Request a prescription for a diuretic.
Administer an additional dose of digoxin.
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Provide 100% oxygen by face mask.
Correct Answer : A,C,G
A. Administer morphine via IV bolus: Morphine is often used in infants with congenital heart defects, such as Tetralogy of Fallot, to reduce agitation, anxiety, and improve oxygenation by reducing systemic vascular resistance. However, this should be done cautiously, as it can decrease respiratory drive and should be administered per specific provider orders.
B. Prepare to assist with the insertion of a chest tube: A chest tube would not be indicated at this moment unless there is evidence of a pneumothorax, hemothorax, or pleural effusion. This scenario does not suggest these conditions.
C. Place the infant in a knee-chest position: This is a classic intervention for infants with Tetralogy of Fallot during a hypercyanotic spell. The knee-chest position increases systemic vascular resistance and reduces the right-to-left shunting of blood, helping to improve oxygenation and reduce cyanosis.
D. Request a prescription for a diuretic: Diuretics are commonly used in infants with congenital heart disease, including Tetralogy of Fallot, to manage fluid retention. This is important for controlling symptoms of heart failure, which may exacerbate cyanosis and respiratory distress.
E. Administer an additional dose of digoxin: While digoxin is used to manage heart failure in infants with congenital heart defects, there is no indication that the infant is in heart failure at this moment, and additional digoxin should only be administered with a provider's order, based on specific clinical needs.
F. Perform nasopharyngeal suctioning for a maximum of 5 seconds: Suctioning should only be performed if the infant is visibly obstructed or struggling with airway clearance. Prolonged or unnecessary suctioning could lead to further agitation and hypoxia in this infant.
G. Provide 100% oxygen by face mask: While oxygen alone isn't always fully effective in tet spells due to the shunting of blood, it's still an important intervention to maximize available oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A normal urinary output in infants is approximately 1-2 mL/kg/hr. An output of 2 mL/kg/hr would indicate that the fluid imbalance is being corrected.
B. An output of 7.5 mL/kg/hr is excessive and may indicate overhydration or other complications.
C. An output of 0.5 mL/kg/hr is too low and suggests that the fluid imbalance is not yet corrected.
D. An output of 15 mL/kg/hr is too high and could indicate a possible issue such as overhydration.
Correct Answer is B
Explanation
A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.
B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.
C. A blood pressure of 90/50 mm Hg is normal for a toddler.
D. A heart rate of 110/min is within the expected range for a 3-year-old.
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