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 D
Explanation
Correct answer: D
A.This can be a good distraction technique, but it might not directly facilitate the lung sound assessment.
B.This activity might help engage the child but could make it difficult for the nurse to listen to breath sounds accurately.
C.Holding a toy might keep the child occupied but does not directly relate to the assessment process and might not ensure cooperation as effectively as using a stethoscope on a stuffed animal.
D.Allowing the child to use the stethoscope on a stuffed animal can help reduce fear and anxiety by making the procedure more familiar and less intimidating. It engages the child in a playful and interactive manner, helping to build trust and cooperation.
Correct Answer is ["A","D","F"]
Explanation
A - Maintaining a consistent home schedule is an essential strategy for managing ADHD, as routines and structure can help the child stay organized and focused.
B - Understanding that nonstimulant medications can also be beneficial in the treatment of ADHD is correct, as nonstimulant medications are an alternative or additional treatment option for some individuals with ADHD. It's important to have a comprehensive understanding of available treatment options.
C - The statement "Know that medication is the best approach to treatment" is not accurate. Medication can be an effective component of ADHD treatment, but it is not necessarily the best approach for every child. Treatment plans should be individualized and may include a combination of strategies, such as behavioral interventions, psychoeducation, and medication.
D - Creating an organization chart for tasks is a helpful approach for children with ADHD to manage their responsibilities and activities effectively.
E - Anticipating being automatically entered into a specialized education plan is not necessarily accurate. While some children with ADHD may benefit from an Individualized Education Plan (IEP) or a 504 Plan in the educational setting, these plans are typically established based on specific assessments and the child's needs.
F - Designating an established area for study is important for creating a distraction-free environment, which can support the child's ability to focus on their schoolwork.
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