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 B
Explanation
Choice A rationale:
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
Choice B rationale:
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits.
Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
Choice C rationale: Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
Choice D rationale: Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
Correct Answer is B, A, E, C, D
Explanation
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
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