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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Nausea and vomiting are potential adverse effects of digoxin in children. Digoxin is a medication commonly used to treat heart conditions, but it can cause gastrointestinal disturbances as a side effect. Nausea and vomiting may occur, especially if the child is receiving too high a dose of digoxin or if they are particularly sensitive to the medication.

B. Improved appetite would not typically indicate an adverse effect of digoxin. In fact, digoxin is not known to have a direct effect on appetite. If a child experienced an increase in appetite while taking digoxin, it would likely be unrelated to the medication or could be due to other factors.

C. Increased urine output would not typically indicate an adverse effect of digoxin. Digoxin is not a diuretic medication, so it would not directly cause increased urine output.

D. Digoxin is not commonly associated with bradycardia in children.

A. Apply oxygen by nasal cannula. B. Administer an anticonvulsant medication. C. Turn the client to a lateral position. D. Check the client's oxygen saturation.

Correct Answer is C

Explanation

C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.

A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.

B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.

D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding would indicate a potential adverse effect of digoxin in a child?

Correct Answer is A

Explanation

A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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