A patient is admitted to the hospital for heart surgery to have a Tetralogy of Fallot repair. The parents are asking the nurse to explain one of the underlying causes of their child's cyanosis. Nurse Lisa is correct in her explanation when she says:

The underlying cause of cyanosis in Tetralogy of Fallot is aortic stenosis.

The underlying cause of cyanosis in Tetralogy of Fallot is a patent ductus arteriosus (PDA).

The underlying cause of cyanosis in Tetralogy of Fallot is mitral valve regurgitation.

The underlying cause of cyanosis in Tetralogy of Fallot is a ventricular septal defect (VSD).

Answer and Explanation

The Correct Answer is D

A. Aortic stenosis affects blood flow from the left ventricle to the aorta, but it is not a component of Tetralogy of Fallot.
B. A patent ductus arteriosus (PDA) is a separate congenital defect and not part of Tetralogy of Fallot.
C. Mitral valve regurgitation is related to left-sided heart valve dysfunction and is not a feature of this condition.
D. One of the four components of Tetralogy of Fallot is a ventricular septal defect (VSD). The VSD, along with pulmonary stenosis, leads to right-to-left shunting of deoxygenated blood, which bypasses the lungs and enters systemic circulation, causing cyanosis.

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Correct Answer is B

Explanation

A. Obtaining a throat culture is contraindicated in suspected epiglottitis because it can cause laryngospasm and complete airway obstruction.
B. Placing the child in an upright position (such as the tripod position) helps to maximize airway patency and ease respiratory distress. This is a safe and supportive measure while preparing for definitive care.
C. While a lateral neck x-ray may be helpful in diagnosis, transporting the child can worsen distress, and airway stabilization takes priority before any diagnostic procedures.
D. Never attempt to visualize the epiglottis with a tongue depressor in suspected cases—this can trigger airway obstruction and is only done in a controlled setting like the OR with emergency airway support available.

A. weight gain B. hyperactivity C. pink mucous membranes D. poor nutritional intake

Correct Answer is D

Explanation

A. Weight gain is typically a sign of adequate nutrition and growth, not a concern for a cardiac defect.
B. Hyperactivity is not characteristic of infants, especially at 1 month of age, and is not a common sign of a cardiac issue in this age group.
C. Pink mucous membranes indicate adequate oxygenation, which does not suggest a cardiac defect.
D. Poor nutritional intake in an infant may signal an underlying cardiac defect, particularly if accompanied by fatigue with feeding, diaphoresis, or failure to thrive. Infants with congenital heart defects often have difficulty feeding due to increased energy expenditure and reduced oxygenation, making this a key red flag.

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A patient is admitted to the hospital for heart surgery to have a Tetralogy of Fallot repair. The parents are asking the nurse to explain one of the underlying causes of their child's cyanosis. Nurse Lisa is correct in her explanation when she says:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The following is found during the assessment of a 1-month-old infant. Which of the following would lead the nurse to suspect a cardiac defect?

Correct Answer is D

Explanation

Nursing care of the infant and child with congestive heart failure would include which of the following?

A 4-year-old is admitted to the ER and is being assessed by a nurse. What are the clinical findings of epiglottitis? (Select All that Apply.)

A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant suddenly becomes cyanotic, and his oxygen saturation reading drops to 60% Choose the interventions the nurse should perform. (Select All that Apply.)

Which of the following drugs is a non-potassium-sparing diuretic for a child with a cardiac condition?

Probably the most important criterion on which to base the decision to report suspected child abuse is which of the following?

The pediatric nurse is caring for a 2-year-old with a respiratory rate of 42 breaths per minute and a FLACC score 8. Which acid-base imbalance does the pediatric team expect to find with sustained tachypnea?

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching?