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 A
Explanation
A. Exposure to environmental tobacco smoke (passive smoking) is a known risk factor for otitis media, as it can irritate the upper respiratory tract and increase susceptibility to respiratory infections, including those affecting the ears.
B. Excessive earwax buildup can sometimes contribute to ear discomfort or hearing problems but it is not a common cause of persistent otitis media. However, it's still important for the nurse to assess for any earwax issues as part of the overall assessment of the child's ear health.
C. Drinking water is generally beneficial for overall health but is not directly linked to otitis media unless there are specific concerns about hydration status or exposure to contaminated water sources.
D. Water entering the ears during bathing is not generally considered a significant risk factor for otitis media, but it can be associated with otitis externa, which is an infection of the outer ear canal.
Correct Answer is D
Explanation
D. This is the correct action to take. A neurovascular check involves assessing the circulation, sensation, and movement in the affected limb. This check helps monitor for complications such as impaired circulation, nerve damage, or compartment syndrome, which can occur after the application of a plaster cast. Regular neurovascular checks are essential for early detection of any issues and appropriate intervention if necessary.
A. Using a hair dryer on a hot setting can cause burns to the skin under the cast. It can also cause the cast material to heat up and potentially cause discomfort or injury to the patient.
B. It's essential to follow the healthcare provider's instructions regarding weight-bearing restrictions, but completely discouraging ambulation can lead to complications such as muscle atrophy, decreased circulation, and increased risk of blood clots.
C. Keeping the client's leg in a dependent position means positioning it lower than the heart. This can increase swelling and exacerbate pain, potentially leading to complications such as compartment syndrome.
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