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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Related Questions
Correct Answer is B
Explanation
Coarctation of the aorta is a congenital heart defect where the aorta, the major blood vessel that carries oxygenated blood from the heart to the body, is narrowed. As a result, blood pressure tends to be higher in the arms and upper body but lower in the lower body, including the legs. This condition can lead to symptoms such as dizziness, headaches, and even nosebleeds due to high blood pressure. Weak or absent lower extremity pulses, as well as pale and cool legs, are characteristic physical findings in coarctation of the aorta.
A. Tetralogy of Fallot: This is a different congenital heart defect characterized by a combination of four specific heart defects, including ventricular septal defect, right ventricular hypertrophy, pulmonary stenosis, and an overriding aorta. It typically does not cause the symptoms described in the scenario.
C. Pulmonic Stenosis: This condition involves the narrowing of the pulmonary valve or artery, leading to restricted blood flow from the right ventricle to the pulmonary artery. While it can cause various symptoms, it typically doesn't cause the specific blood pressure discrepancies described.
D. Tricuspid Atresia: This is a congenital heart defect where the tricuspid valve is absent or abnormally developed. It leads to the mixing of oxygenated and deoxygenated blood in the heart. While it can cause cyanosis (bluish skin due to low oxygen levels), it doesn't typically cause the specific blood pressure findings mentioned.
Correct Answer is B
Explanation
Decreased cardiac output is a common consequence of various cardiac conditions in children. In this scenario, the child's cool extremities and thready pulses indicate poor peripheral perfusion, which can occur when the heart is not effectively pumping blood to meet the body's demands. Decreased urinary output is another sign of poor cardiac output, as reduced blood flow to the kidneys can result in decreased urine production.
The other options may contribute to decreased cardiac output, but they are not the primary factors indicated by the clinical findings:
A. Increased afterload: Increased afterload can make it more difficult for the heart to pump blood effectively, but it is not the primary cause of the symptoms described.
C. Decreased contractility: Decreased contractility can reduce the heart's ability to pump blood, contributing to decreased cardiac output, but it is not the primary factor indicated by the clinical findings.
D. Increased stroke volume: An increase in stroke volume typically results in improved cardiac output, not diminished cardiac output as seen in this scenario.
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