A nurse is caring for an infant who has tetralogy of Fallot. The infant is crying and is experiencing a hypercyanotic spell. Which of the following actions should the nurse take first?
Administer morphine subcutaneously.
Apply a face mask supplying 100% oxygen.
Attempt to calm and soothe the child.
Place the infant in a knee-chest position.
The Correct Answer is B
Choice A rationale:
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
Choice B rationale:
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
Choice C rationale:
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
Choice D rationale:
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
Choice B rationale:
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
Choice C rationale:
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
Choice D rationale:
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
Correct Answer is D
Explanation
Choice A rationale:
Eliminating unhealthy foods is generally a good practice, but specific guidance related to managing hyperemesis gravidarum is needed.
Choice B rationale:
Dairy products can be included in the diet unless the client has a specific intolerance or allergy.
Choice C rationale:
Drinking water with each meal can be helpful, but avoiding dehydration is more important. Fluid intake should be consistent throughout the day.
Choice D rationale:
Hyperemesis gravidarum is a condition that causes severe nausea and vomiting during pregnancy, which can lead to dehydration, electrolyte imbalance, and weight loss. To prevent or reduce these complications, the nurse should instruct the client to eat foods at colder temperatures, as they are less likely to trigger nausea than hot or spicy foods. The client should also eat small, frequent meals and avoid foods that are greasy, fatty, or have strong odors.
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