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(Select all that apply):.
A nurse is performing a nursing assessment on a child with a congenital heart defect.
Which aspects should the nurse include in the assessment? Select all that apply.

Physical examination.

Growth and development assessment.

Oxygen saturation monitoring.

Feeding assessment.

Genetic testing.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale:

A physical examination is an essential part of the nursing assessment for a child with a congenital heart defect.

It helps the nurse identify physical signs and symptoms that may be indicative of the heart defect.

Choice B rationale:

Assessing growth and development is crucial when caring for a child with a congenital heart defect.

This helps monitor the child's overall health and well-being and can detect any developmental delays or issues related to the heart condition.

Choice C rationale:

Oxygen saturation monitoring is important for children with congenital heart defects as it helps assess the effectiveness of their oxygen delivery and may indicate the need for interventions or adjustments in their care.

Choice D rationale:

A feeding assessment is necessary for children with congenital heart defects as they may experience difficulties with feeding due to limited energy and respiratory issues.

Ensuring adequate nutrition is essential for their growth and development.

Choice E rationale:

Genetic testing is not typically a part of the routine nursing assessment for a child with a congenital heart defect.

While some heart defects may have a genetic component, this is not a standard part of the assessment process.

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Correct Answer is B

Explanation

Prepare for emergency surgery.

Choice A rationale:

Administer oxygen therapy immediately.

Administering oxygen therapy would provide temporary relief to the patient's cyanosis, but it does not address the underlying issue in Tetralogy of Fallot (TOF).

TOF is a congenital heart defect characterized by a combination of four heart abnormalities, one of which is a ventricular septal defect (VSD) that allows oxygen-poor blood to mix with oxygen-rich blood.

Administering oxygen will increase the oxygen saturation in the blood but will not fix the structural problem.

The immediate priority for a patient with TOF experiencing a hypercyanotic spell is to address the heart defect itself.

Choice B rationale:

Prepare for emergency surgery.

In Tetralogy of Fallot, hypercyanotic spells, also known as "tet spells," are a medical emergency.

These spells occur due to a sudden decrease in systemic vascular resistance, causing more blood to flow into the right ventricle, leading to increased right-to-left shunting, further decreasing oxygenation.

The most appropriate intervention is to prepare for emergency surgery to correct the underlying cardiac defects, such as closing the VSD and relieving right ventricular outflow obstruction.

Surgery is the definitive treatment for TOF and should be performed promptly during a tet spell to prevent severe hypoxia and potential long-term complications.

Choice C rationale:

Monitor vital signs closely.

While monitoring vital signs is essential in the care of a patient with TOF, it is not the most immediate response in the scenario of a hypercyanotic spell.

Monitoring alone will not address the critical need for intervention to improve oxygenation and prevent hypoxia.

Choice D rationale:

Administer prescribed medication.

Administering prescribed medication may be part of the overall management of a patient with TOF, but it is not the immediate response during a hypercyanotic spell.

Medications can help manage symptoms and stabilize the patient, but the definitive treatment for TOF is surgical correction.

A. Genetic factors. B. Maternal health. C. Exposure to infections during pregnancy. D. Chromosomal abnormalities. E. Paternal health.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:

Genetic factors can contribute to the development of congenital heart defects in children.

Certain genetic mutations or abnormalities can increase the risk of congenital heart conditions.

Choice B rationale:

Maternal health is a factor that may contribute to the development of congenital heart defects in children.

Maternal conditions such as diabetes or rubella during pregnancy can increase the risk of congenital heart defects in the fetus.

Choice C rationale:

Exposure to infections during pregnancy is a known risk factor for the development of congenital heart defects.

Infections like rubella and certain medications can increase the risk of congenital heart conditions.

Choice D rationale:

Chromosomal abnormalities, such as Down syndrome (Trisomy 21), can be associated with congenital heart defects.

These genetic abnormalities can impact the development of the heart.

Choice E rationale:

While paternal health is important for overall fetal development, it is not a well-established risk factor for congenital heart defects.

The primary factors are maternal and genetic.

Congenital heart defects in children can be influenced by a combination of genetic factors, maternal health, exposure to infections during pregnancy, and chromosomal abnormalities.

These factors interact to increase the risk of congenital heart conditions.

Therefore, choices A, B, C, and D are all correct answers.

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(Select all that apply):.A nurse is performing a nursing assessment on a child with a congenital heart defect.Which aspects should the nurse include in the assessment? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A client diagnosed with Tetralogy of Fallot (TOF) presents with cyanosis that worsens with crying or feeding; clubbing of fingers and toes; poor feeding, weight gain, or growth; polycythemia; hypercyanotic spells (“tet spells”).What should be the nurse's immediate response?

Correct Answer is B

Explanation

(Select all that apply): A nurse is educating a group of parents about congenital heart defects in children.Which factors may contribute to the development of congenital heart defects in children? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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A nurse is providing nursing interventions for a child with a congenital heart defect.What is an example of a medication that may be administered as prescribed to this child?

(Select all that apply):.
A nurse is performing a nursing assessment on a child with a congenital heart defect.
Which aspects should the nurse include in the assessment? Select all that apply.