Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Position the infant in a knee-chest position.
Administer morphine via IV bolus.
Provide 100% oxygen by face mask.
The Correct Answer is B
Choice A rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a recommended action for an infant diagnosed with Tetralogy of Fallot. This procedure is typically used to clear the airway in infants with respiratory distress, not heart conditions.
Choice B rationale
Positioning the infant in a knee-chest position can help increase blood flow to the lungs, which is beneficial for an infant with Tetralogy of Fallot. This condition involves a combination of heart defects that affect the normal flow of blood through the heart.
Choice C rationale
Administering morphine via IV bolus is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine is a powerful pain reliever, it is not typically used in the management of this condition.
Choice D rationale
Providing 100% oxygen by face mask is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While supplemental oxygen can help increase the amount of oxygen in the blood, it does not address the underlying heart defects associated with this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.
Correct Answer is ["90"]
Explanation
The correct answer is less than 90 beats per minute.
Step 1 is to understand the guidelines for administering digoxin to infants. According to the American Academy of Pediatrics, the nurse should withhold the dose if the infant’s apical heart rate is less than 90 beats per minute.
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