An 8-month-old infant has a hyper-cyanotic Tet spell while blood is being drawn. Which of the following should the nurse's first action be?

Prepare the family for the child's imminent death

Begin cardiopulmonary resuscitation compressions

Assess for neurologic defects

Administer oxygen by face mask

Answer and Explanation

The Correct Answer is D

A. Preparing the family for imminent death is premature and inappropriate as the first action. Hyper-cyanotic spells (Tet spells) are medical emergencies but often reversible with prompt intervention.
B. CPR is not the first response unless the child is unresponsive and pulseless. Tet spells are managed with specific interventions to reduce hypoxia.
C. Assessing for neurological defects may be important later, but during an acute Tet spell, the priority is to restore oxygenation and stabilize the child.
D. The first action during a Tet spell is to administer oxygen to reduce pulmonary vasoconstriction and improve oxygenation. This is often followed by placing the child in a knee-chest position, giving morphine, and preparing for further medical support as needed. Oxygen is the most immediate, non-invasive intervention.

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Correct Answer is C

Explanation

A. Children with Down syndrome typically exhibit short stature, not excessive height.
B. While children with Down syndrome may have a single transverse palmar crease, not "spots on the palms," this is not the most defining physical feature.
C. One of the hallmark physical characteristics of Down syndrome is hypotonia (low muscle tone). It often leads to delayed motor development, poor head control, and floppy posture in infancy.
D. Children with Down syndrome are more likely to have hyperflexible joints due to ligamentous laxity, not inflexibility.

A. Apply direct pressure 1 inch above the puncture site B. Notify the Cardiac Cath Lab that the child will be returning C. Place a call to the Interventional Radiologist D. Apply a bulky pressure dressing over the present dressing

Correct Answer is A

Explanation

A. Bright red blood indicates active arterial bleeding, most likely from the femoral artery used during the cardiac catheterization. The first priority is to stop the bleeding. Direct pressure should be applied just above the puncture site to help control the bleeding and prevent further blood loss.
B. While notifying the Cath Lab may be necessary later, intervention to stop the bleeding must come first to ensure patient safety.
C. Contacting the Interventional Radiologist may eventually be required, but it is not the first action. Immediate pressure to control bleeding is more urgent.
D. Applying a bulky dressing alone without direct pressure is inadequate in managing arterial bleeding and may delay life-saving intervention.

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An 8-month-old infant has a hyper-cyanotic Tet spell while blood is being drawn. Which of the following should the nurse's first action be?

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Naxlex Comprehensive Predictor Exams

While teaching anticipatory guidance to a young couple with a child with Down syndrome, the nurse explains that one major physical characteristic of the child with Down syndrome is:

Correct Answer is C

Explanation

The nurse is caring for a child who has undergone cardiac catheterization. During the recovery, the nurse notices that the dressing is saturated with bright red blood. The nurse's first action is to:

Correct Answer is A

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