An infant with Tetralogy of Fallot (TOF) is having a hypercyanotic episode. Which nursing interventions should the nurse implement? (Select All that Apply.)
Place the child in knee-chest position.
Administer oxygen.
Administer albuterol as ordered.
Administer morphine sulfate intravenously as ordered.
Draw blood for a serum hemoglobin.
Correct Answer : A,B,D
A. The knee-chest position increases systemic vascular resistance and helps relieve the hypercyanotic episode.
B. Administering oxygen can help improve oxygen saturation and alleviate the cyanosis during a hypercyanotic episode.
C. Albuterol is typically not used for hypercyanotic episodes; it's more useful for bronchodilation in asthma.
D. Morphine sulfate may be used to decrease the respiratory effort and calm the infant during a hypercyanotic episode.
E. Drawing blood for a serum hemoglobin is not an immediate intervention for a hypercyanotic episode. The focus should be on managing the episode itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing infants on their backs to sleep significantly reduces the risk of sudden infant death syndrome (SIDS). This is the primary prevention recommendation.
B. SIDS rates have decreased in recent years due to increased awareness and safe sleep practices.
C. There is no direct correlation between SIDS and the diphtheria, tetanus, and pertussis vaccines.
D. Sleep apnea is not the main cause of SIDS, although it can be related to sleep-related breathing issues in some infants.
Correct Answer is C
Explanation
A. Vegetables are often introduced after cereals and fruits due to their less sweet taste.
B. Meats are usually introduced later, after cereals and fruits.
C. The recommended order for introducing solid foods to infants is starting with cereals (such as rice cereal), followed by fruits, and then meats. This order helps the infant adapt to new textures and flavors gradually.
D. While cereals and vegetables can be introduced early, meats are typically added after fruits.
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