During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
Evaluate infant for failure to thrive (FTT).
Auscultate heart and lungs while infant is held.
Stimulate the infant to cry to produce cyanosis.
Obtain a 12-lead electrocardiogram.
The Correct Answer is B
A. Evaluating the infant for failure to thrive (FTT) is not the most appropriate initial intervention in this case. FTT is a long-term growth issue, and the immediate concern is the infant's current symptoms and cardiac status.
B. Auscultate heart and lungs while the infant is held.
Tetralogy of Fallot (TOF) is a congenital heart defect that includes four specific cardiac abnormalities, and it often requires surgical correction in infancy. When an infant with a history of TOF surgery presents with symptoms such as rapid breathing, feeding difficulties, and fatigue, it may raise concerns about potential cardiac issues or complications.
The most appropriate initial intervention is to auscultate the infant's heart and lungs while the infant is held to assess for any abnormal heart sounds or signs of respiratory distress. Auscultation can provide important information about the infant's cardiac and respiratory status. This assessment will help determine if there are any immediate concerns related to the infant's cardiac condition.
C. Stimulating the infant to cry to produce cyanosis is not a recommended or appropriate intervention. Cyanosis is a sign of inadequate oxygenation and should not be induced in a child.
D. Obtaining a 12-lead electrocardiogram may be indicated if there are significant concerns about the infant's cardiac status, but auscultation should be performed first to assess the immediate condition. An electrocardiogram is a diagnostic tool and would be ordered as a follow-up assessment if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The mother being a single parent and living with her parents may have an impact on the family dynamics and support system but is not the most significant finding when it comes to addressing the baby's sleep issues.
B. The baby being irritable during feedings is important information and should be addressed, but it may not be the most significant finding when it comes to the baby's sleep patterns.
C. The diaper area shows severe skin breakdown.
Severe skin breakdown in the diaper area can be indicative of several issues, including frequent diaper changes, diaper rash, or potential underlying health concerns. This finding suggests that the infant may have discomfort or pain related to the diaper area, which could be contributing to the baby's nighttime awakenings and sleep disturbances.
D. The infant's formula being changed twice may be relevant, but it is not as significant as severe skin breakdown, which can indicate immediate discomfort for the baby.
Correct Answer is A
Explanation
A. Osteosarcoma.
The presentation of localized knee pain, especially when it worsens at night, along with swelling, tenderness, and the presence of radial ossification in the soft tissues, raises concerns about the possibility of osteosarcoma. Osteosarcoma is a malignant bone tumor that commonly occurs in the long bones of the body, such as the femur, and often presents with these clinical features.
B. Rhabdomyolysis is a condition that results from the breakdown of muscle tissue and typically presents with symptoms such as muscle pain, weakness, and dark urine due to the release of muscle proteins into the bloodstream. It is not the likely cause of the findings described.
C. Growing pains are typically characterized by intermittent, mild, and diffuse musculoskeletal pain and discomfort in children and adolescents. They do not typically involve localized knee pain, swelling, or tenderness.
D. Hemosiderosis refers to the accumulation of iron in the body and is not typically associated with the described findings or symptoms.
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