The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
"If the baby turns blue, I will immediately put the baby upright in an infant seat."
"If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body."
"If the baby turns blue, I will put the baby in supine position with his head elevated."
"If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest."
The Correct Answer is D
This position, often referred to as the "knee-to-chest" position, is recommended during a cyanotic spell in infants with tetralogy of Fallot because it can help increase venous return to the heart and improve oxygenation. It's important for caregivers to understand this positioning as part of the management for hypercyanotic spells in children with this condition.
A. Placing the baby upright in an infant seat may help improve blood flow and oxygenation, but it's not the recommended position for managing cyanosis in a baby with tetralogy of Fallot.
B. Placing the baby with the head lower than the rest of the body could potentially worsen cyanosis by increasing right-to-left shunting of blood and decreasing pulmonary blood flow.
C. Placing the baby in a supine position with the head elevated worsens pulmonary blood flow by increasing systemic vascular resistance. This position can help worsen cyanosis by promoting better oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.
A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.
B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.
C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.
Correct Answer is B
Explanation
B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.
A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.
C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.
D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today