Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Choice A rationale
Positioning the infant supine is not the most appropriate intervention for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. This position could put pressure on the sac and potentially lead to rupture or infection.
Choice B rationale
While contact precautions can be important in certain situations to prevent the spread of infection, they are not the primary intervention for a child with spina bifida undergoing surgery. The main concern is protecting the myelomeningocele sac from damage and infection.
Choice C rationale
Ensuring a latex-free environment is crucial for a child with spina bifida. Many children with spina bifida have a latex allergy, and exposure to latex can cause an allergic reaction. This can range from skin redness and itching to more serious symptoms such as wheezing and difficulty breathing.
Choice D rationale
Restricting visitors to immediate family members is not specifically related to the care of an infant with spina bifida. While limiting visitors can help reduce the risk of infection, it is not the primary concern in this case.

Choice A rationale
Gestational hypertension is characterized by high blood pressure that develops after 20 weeks of pregnancy and typically resolves within a few weeks postpartum. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage.
However, Sarah’s condition does not fit this description because her blood pressure has been consistently high since she was 26, not just during pregnancy.
Choice B rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. Given Sarah’s history of consistent high blood pressure since age 26 and her recent seizure at 32 weeks’ gestation, this choice fits her condition.
Choice C rationale
Gestational hypertension refers to high blood pressure that begins during pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. However, Sarah’s high blood pressure did not begin during pregnancy, making this choice incorrect.
Choice D rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. HELLP Syndrome (Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels) is a serious health condition that can affect pregnant women3. However, Sarah’s symptoms do not indicate HELLP Syndrome, making this choice incorrect.