An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
Prepare family for imminent death
Place the child in the knee-chest position
Assess for neurologic defects
Begin cardiopulmonary resuscitation
The Correct Answer is B
Hypercyanotic spells, also known as "Tet spells," can occur in infants with congenital heart defects, particularly tetralogy of Fallot. During these spells, there is a sudden decrease in oxygen saturation, leading to cyanosis (blueness) of the infant's skin and lips, as well as respiratory distress and possible loss of consciousness.
The knee-chest position is a specific technique used to manage hypercyanotic spells. Placing the child in this position helps improve oxygenation by increasing systemic vascular resistance and reducing the degree of right-to-left shunting of blood in the heart. It also increases venous return to the heart, which can help improve cardiac output.
Now, let's discuss why the other options are incorrect:
A. Prepare family for imminent death: This is not the priority action. While hypercyanotic spells can be life-threatening, the immediate focus should be on managing the spell to improve oxygenation and prevent further deterioration. Preparing the family for death should only be considered if resuscitation measures fail, which is not the first-line intervention.
C. Assess for neurologic defects: Assessing for neurologic defects is important but not the immediate priority during a hypercyanotic spell. The primary concern at this moment is addressing cyanosis and respiratory distress to ensure the infant receives adequate oxygen.
D. Begin cardiopulmonary resuscitation: Initiating CPR is not the initial priority during a hypercyanotic spell. CPR would be indicated if the infant's condition deteriorates to the point of cardiac arrest, but it should not be the first step. Placing the child in the knee-chest position is a non-invasive intervention that should be attempted before considering CPR.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When obtaining the history of a child with suspected rheumatic fever, the nurse should consider the following information to be most significant:
B. A recent episode of pharyngitis.
Explanation:
Rheumatic fever often follows an untreated or inadequately treated streptococcal pharyngitis (strep throat) infection caused by Group A Streptococcus bacteria. Therefore, a recent episode of pharyngitis is a key piece of information in the context of rheumatic fever. It is important to assess whether the child had a sore throat, fever, and other symptoms of streptococcal infection that may have triggered the development of rheumatic fever.
While the other symptoms (vomiting, lack of interest in food, fever) may be important for the overall assessment and management of the child, they are not as directly associated with the development of rheumatic fever as a recent episode of pharyngitis caused by Group A Streptococcus. Rheumatic fever is an autoimmune response to untreated streptococcal infection, and its diagnosis is often linked to the presence of preceding streptococcal pharyngitis.
Correct Answer is D
Explanation
Tetralogy of Fallot is a congenital heart defect characterized by a combination of four specific heart abnormalities:
Ventricular septal defect (VSD): A hole in the wall (septum) between the two lower chambers (ventricles) of the heart.
Overriding aorta: The aorta is positioned over both the left and right ventricles, allowing oxygen-poor (deoxygenated) blood from the right ventricle to mix with oxygen-rich (oxygenated) blood from the left ventricle.
Pulmonic stenosis: Narrowing of the pulmonary valve or artery, which restricts blood flow from the right ventricle to the lungs.
Right ventricular hypertrophy: The right ventricle becomes thicker and more muscular as it works harder to pump blood against the narrowed pulmonary valve or artery.
The combination of these defects results in deoxygenated blood from the right ventricle being pumped into the systemic circulation, leading to cyanosis (blueness of the skin) due to decreased oxygen levels in the arterial blood.
The other options (A, B, and C) describe different congenital heart defects but do not specifically result in cyanosis due to deoxygenated blood entering the systemic circulation:
A. Coarctation of the aorta results in the narrowing of the aorta but does not directly lead to cyanosis from the mixing of oxygen-poor blood.
B. Aortic stenosis involves narrowing of the aortic valve but does not typically result in cyanosis in the same way as Tetralogy of Fallot.
C. Patent ductus arteriosus (PDA) involves a connection between the aorta and pulmonary artery but does not cause cyanosis from mixing to the extent seen in the Tetralogy of Fallot.
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