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","C","E"]
Explanation
2100: Child brought into the emergency department by their guardians. The child has Acute Lymphoblastic Leukemia (ALL) and is currently in the induction phase of treatment for standard risk. The child received chemotherapy with vincristine 8 days ago and is taking daily oral steroids. Child is alert, crying, and clinging to guardian. Guardians report the child has not had a bowel movement for 5 days.
2100:
Pulse 120/min
Respiratory rate 25/min
Temperature 38.8° C (101.9° F) tympanic
SaO2 96% on room air
2120: Child now asleep in guardian's arms. Respirations unlabored, heart rate regular. Child has a double-lumen central line catheter in the left chest wall. Insertion site is erythematous with a scant amount of purulent drainage.
Rationale:
Temperature of 38.8°C (101.9°F) tympanic: Fever in a child with leukemia is concerning as it may indicate an infection, especially since the child is immunocompromised due to chemotherapy. This needs immediate follow-up and potentially blood cultures to determine the source of infection.
Erythema and purulent drainage at central line insertion site: Purulent drainage and erythema at the central line insertion site suggest a possible infection, such as a catheter-associated bloodstream infection. This requires prompt follow-up, possibly including antibiotic therapy and further investigations to prevent sepsis.
Child has not had a bowel movement for 5 days: Constipation is a common side effect of chemotherapy and oral steroids, but a delay in bowel movements could indicate bowel obstruction or other gastrointestinal issues. This needs to be addressed, and the child may require laxatives or further investigation.
Correct Answer is A
Explanation
Rationale:
A. Orthostatic hypotension (a significant drop in blood pressure when standing) could indicate a problem such as dehydration, hemorrhage, or shock and should be reported immediately.
B. Crying due to pain is common with burn injuries but does not indicate a life-threatening problem.
C. A pain increase after ambulation is expected in some cases but is not an emergency.
D. A mild temperature (99.5°F) postoperatively is not a cause for immediate concern.
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