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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While inappropriate parental concern can raise suspicion, it is subjective and not as reliable or definitive as physical evidence and history.
B. The most important and objective red flag for suspected child abuse is when the injury does not match the explanation given. This incompatibility strongly suggests that the injury may have been caused intentionally or through neglect, and it warrants immediate reporting.
C. A child’s response can be influenced by fear, trauma, or developmental stage and is not always a clear indicator of abuse.
D. Absence of parents may be suspicious, but it does not confirm abuse and is not sufficient alone to report without supportive findings.
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.
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