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","B","D"]
Explanation
A. Wheezing. Cystic fibrosis can cause airway obstruction due to thickened mucus, leading to wheezing and difficulty breathing, especially during respiratory infections or exacerbations.
B. A barrel-shaped chest is often seen in advanced stages of cystic fibrosis. It results from hyperinflation of the lungs due to air trapping, chronic lung disease, and repeated respiratory infections. The chest appears rounded and enlarged, similar to the shape of a barrel.
D. Clubbing of fingers and toes is a common finding in cystic fibrosis. It is caused by chronic hypoxia and inadequate oxygenation of tissues, leading to changes in the nail beds and fingertips. Clubbing typically develops over time in individuals with chronic respiratory conditions, including cystic fibrosis.
C. Thin, watery mucous is not expected in cystic fibrosis. Instead, cystic fibrosis is characterized by thick, sticky mucus due to dysfunction of the exocrine glands, leading to blockages in the airways, pancreas, and other organs.
E. Rapid growth spurts are not typically associated with cystic fibrosis. In fact, children with cystic fibrosis may experience growth failure or delayed growth due to malabsorption of nutrients, chronic illness, and increased energy expenditure.
Correct Answer is A
Explanation
A. Frequent swallowing is a common finding after a tonsillectomy due to postoperative throat discomfort and the sensation of having a foreign object in the throat (such as blood clots or mucus).
B. Reports of thirst may indicate dehydration, which can occur after surgery, especially if the child is not drinking enough fluids due to pain or discomfort. While dehydration can be a concern after a tonsillectomy, it is not a specific sign of hemorrhage.
C. Pain is common after a tonsillectomy and can be expected in the postoperative period. While increased pain may be present if hemorrhage occurs, it is not a specific sign of hemorrhage on its own.
D.Mouth breathing does not directly indicate bleeding and is more related to discomfort or difficulty breathing through the nose, especially if the child is experiencing throat pain. It is not a typical sign of hemorrhage.
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