An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?
Administer oxygen.
Place the infant in Trendelenburg position.
Draw blood for a serum hemoglobin.
Place the infant in knee-chest position.
Administer morphine as ordered.
Correct Answer : A,D,E
Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Fracturing a bone through the epiphyseal plate does not put a child at risk for developing Rheumatoid Arthritis, which is an autoimmune condition unrelated to such injuries.
Choice B reason: Permanent nerve damage is not a typical consequence of fracturing the epiphyseal plate, as this injury primarily affects bone growth.
Choice C reason: The epiphyseal plate, or growth plate, is responsible for the longitudinal growth of bones in children and adolescents. Damage to this area can disrupt normal bone growth.
Choice D reason: While severe damage to the epiphyseal plate can potentially halt growth in that bone, it is more common for the growth to be disrupted rather than completely prevented. The extent of the impact depends on the severity of the injury.
Correct Answer is B
Explanation
Choice A reason: Clubbed fingers are a sign of chronic hypoxia and may be seen in older children with cystic fibrosis, but they are not typically present at birth.
Choice B reason: This is the correct choice. Meconium ileus is a blockage of the intestines that occurs shortly after birth and is often the first sign of cystic fibrosis.
Choice C reason: A barrel chest is associated with chronic respiratory conditions and would not be present in a newborn.
Choice D reason: Steatorrheic stools, or fatty stools, may occur in cystic fibrosis but are not a primary indicator in a newborn.
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