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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.
Correct Answer is D
Explanation
Choice A reason: While a high-pitched cry can be a sign of distress, it is not a specific indicator of increased intracranial pressure.
Choice B reason: Decreased movement in the lower extremities can indicate a neurological issue but is not a specific sign of increased intracranial pressure.
Choice C reason: Excessive wet diapers are not related to intracranial pressure.
Choice D reason: This is the correct choice. A bulging fontanel, especially when crying, can indicate increased intracranial pressure in an infant. It is important to monitor for other signs and symptoms as well.
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