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 forward bending test, also known as the Adam's forward bend test, is commonly used to screen for idiopathic scoliosis. During this test, the child is instructed to bend forward from the waist with their arms hanging downward and palms touching or overlapping. This position allows the nurse to observe the child's back for asymmetry, rib humps, or other signs of spinal curvature characteristic of scoliosis.

A This position may be used for certain examinations, such as assessing the spine's curvature but it is not typically the position used for screening for idiopathic scoliosis.
B This instruction involves cervical spine movement and is not relevant to screening for idiopathic scoliosis. It may be part of a different examination, such as assessing cervical spine range of motion or neurological function, but it does not aid in detecting scoliosis.
C Turning to the side and remaining relaxed may not provide adequate visualization of the spine's curvature, which is essential for scoliosis screening. Additionally, this position does not allow for proper assessment of the spine's alignment.
Correct Answer is D
Explanation
D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.
A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.
B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.
C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).
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