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. Wheezing is more common in lower airway diseases like asthma.
B. Drooling and diaphoresis are more indicative of epiglottitis.
C. Crackles are associated with lower respiratory tract infections like pneumonia.
D. Inspiratory stridor is a hallmark sign of laryngotracheobronchitis (croup), resulting from upper airway narrowing and inflammation.
Correct Answer is C
Explanation
A. Mummy restraints immobilize the entire body, which is unnecessary for this procedure.
B. Jacket restraints are typically used for older children and not appropriate for an infant.
C. Elbow restraints are used to prevent the infant from bending their arms, which helps avoid touching or putting pressure on the surgical site after cleft lip and palate repair.
D. Wrist restraints do not prevent the infant from moving their arms enough to protect the surgical site.
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