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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. If an orogastric tube fails to pass, it may indicate a blockage or abnormal connection, such as a tracheoesophageal fistula.
Choice B reason: Low birth weight can be associated with many conditions and is not specific to TEF.
Choice C reason: TEF is not typically visible without special imaging or procedures; it cannot be visually identified at delivery.
Choice D reason: Dry mouth and nares with little to no oral secretions could indicate other conditions and are not specific to TEF. TEF often presents with excessive oral secretions.
Correct Answer is A
Explanation
Choice A reason: School-age children, typically around the ages of 6 to 12, begin to grasp the finality and irreversibility of death. They understand that death is universal and affects all living things.
Choice B reason: Preschool-age children may have some concept of death, but they often view it as reversible or temporary, not fully understanding its permanence.
Choice C reason: Toddlers are too young to comprehend the concept of death, as their cognitive development at this stage does not allow for such abstract thinking.
Choice D reason: While adolescents certainly understand the permanence of death, this awareness develops earlier, during the school-age years. Adolescents may begin to explore more complex philosophical and existential questions about life and death.
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