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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.

Answer and Explanation

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.

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

Explanation

A. Buying toys for a child may be a kind gesture, but it does not directly contribute to building a therapeutic relationship.

B. Asking questions if families are not participating in care helps engage them and supports their involvement in the child’s care.

C. Clarifying information for families ensures that they understand their child's condition and care plan, fostering trust and communication.

D. Spending off-duty time with families may blur professional boundaries and is not recommended for maintaining a therapeutic relationship.

E. Learning about the family’s religious preferences helps the nurse provide culturally sensitive care and supports the family’s needs.

A. Decreased attention span B. Hyperactivity C. Tachycardia D. Hypotension

Correct Answer is A

Explanation

A. Decreased attention span is a common manifestation of increased intracranial pressure, as pressure on the brain can affect cognitive function.

B. Hyperactivity is not typically associated with increased intracranial pressure. It would be more common for the child to exhibit lethargy or irritability.

C. Tachycardia is not a primary symptom of increased intracranial pressure. Typically, bradycardia (slow heart rate) is seen in cases of severe intracranial pressure.

D. Hypotension is not usually associated with increased intracranial pressure. In fact, increased intracranial pressure often leads to elevated blood pressure and a widening pulse pressure.

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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.)

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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.)