An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
Place the infant in the knee-chest position.
start an IV for fluids.
Prepare the infant for surgery
Raise the head of the bed.
The Correct Answer is A
A. Place the infant in the knee-chest position: In a hypercyanotic (“Tet”) spell, placing the infant in a knee-chest position increases systemic vascular resistance, reduces right-to-left shunting, and improves pulmonary blood flow and oxygenation. Immediate positioning is a first-line emergency intervention.
B. Start an IV for fluids: Establishing IV access is important for administering medications and fluids, but it is secondary to immediate measures to relieve cyanosis and improve oxygenation during a Tet spell.
C. Prepare the infant for surgery: Surgical repair is definitive treatment for tetralogy of Fallot, but emergent stabilization takes priority before operative intervention can occur.
D. Raise the head of the bed: Elevating the head may aid comfort and respiratory mechanics in some conditions, but it does not address the acute pathophysiology of right-to-left shunting causing cyanosis during a Tet spell.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine the child’s preferred method of communication: Identifying whether the child uses sign language, lip reading, gestures, or assistive devices is essential for effective communication. Tailoring interactions to the child’s preferred method promotes language development, social interaction, and learning opportunities.
B. Assess the child’s hearing and visual capabilities: While important for overall assessment, these evaluations provide baseline data but do not directly facilitate immediate communication strategies or support language development.
C. Encourage the parent to have the child participate in activities that promote adaptation: Participation in adaptive activities supports social and emotional growth, yet without knowing the child’s preferred communication method, these interactions may be less effective for promoting language and communication skills.
D. Serve meals at the child’s usual mealtimes: Maintaining routine mealtimes supports predictability and general care, but it does not directly address communication development or language acquisition.
Correct Answer is B
Explanation
A. September 17th, 2017: Calculating EDD by subtracting three months from the LMP and adding seven days would place the date earlier than the accurate estimate. This does not account correctly for the standard adjustment used in Nägele’s Rule.
B. September 24th, 2017: Nägele’s Rule estimates the EDD by taking the first day of the last menstrual period, subtracting three months, and adding seven days. Starting from December 17th, 2016, subtracting three months gives September 17th, 2016, then adding seven days results in September 24th, 2017, providing the correct estimated delivery date.
C. October 10th, 2016: This date is inconsistent with gestational length calculations. It falls too early relative to the standard 280-day pregnancy duration and does not follow Nägele’s Rule calculations.
D. October 24th, 2017: This date overestimates gestation length by approximately one month. Adding seven days to the correct calculation places the EDD in late September rather than late October, making it inaccurate according to standard obstetric estimation.
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