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.
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Related Questions
Correct Answer is D
Explanation
A. Birth weight typically triples by 12 months, not doubles.
B. Birth weight typically doubles by 6 months, not 9 months.
C. Birth weight does not double by 3 months, but by 6 months.
D. Birth weight typically doubles by 6 months of age. This is a key developmental milestone in infancy.
Correct Answer is C
Explanation
A. Initiative versus guilt is the psychosocial stage of preschool-aged children (3 to 6 years).
B. While sexual curiosity may emerge in early childhood, it is more prominent during the preschool years rather than the toddler stage.
C. Toddlers are typically in Erikson's stage of autonomy versus shame and doubt, which is characterized by the development of independence and sometimes negative behaviors as they assert their autonomy.
D. Imaginary playmates are common in preschool-aged children, not toddlers.
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