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 C
Explanation
Choice A rationale:
A 64-year-old client taking estrogen supplements does not necessarily indicate a greater risk for infection compared to the other options.
Choice B rationale:
A 70-year-old client with COPD does not necessarily indicate a greater risk for infection compared to the other options.
Choice C rationale:
A 28-year-old client with a left arm fracture is at greater risk for infection due to the open wound and potential introduction of pathogens.
Choice D rationale:
A 53-year-old client with a thin build does not necessarily indicate a greater risk for infection compared to the other options.
Correct Answer is C
Explanation
A: Expecting heavier menstrual bleeding while using the patch is not a typical instruction given to clients. The patch may actually result in lighter, more regular bleeding.
B: The patch should not be placed on the upper thigh. According to the guidelines, the patch should be applied to clean, dry skin on the belly, buttocks, or back, and can also be placed on the outer part of the upper arm.
C: Applying the first patch within 24 hours of starting the menstrual cycle is correct. This ensures that the patch begins to work in sync with the client's natural cycle, providing immediate contraceptive protection.
D: A new patch should not be applied at the same time each day. Instead, it should be changed once a week on the same day, known as the "patch change day" to maintain consistent contraceptive coverage.
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