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The nurse if giving instructions to parents of a 4-month-old infant with tetralogy of fallot. An important teaching point should include:

A.

Add rice cereal to her formula to increase her calories

B.

If the infant becomes blue and is breathing deeply, put her in the knee-chest position

C.

If the infant becomes blue and is breathing deeply, put her in trendelenburg position

D.

Feed the infant every 2 hours around the clock.

Answer and Explanation

The Correct Answer is B

A. Adding rice cereal could cause excess work on the heart and worsen symptoms. The focus should be on low-stress feeding.

B. Knee-chest position increases systemic vascular resistance, which helps relieve hypercyanotic spells (tet spells) in infants with tetralogy of Fallot.

C. Trendelenburg position is not effective for relieving cyanosis in this condition.

D. The infant with tetralogy of Fallot should be fed smaller, more frequent meals rather than every 2 hours. 


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A","dropdown-group-4":"A","dropdown-group-5":"A"}

Explanation

The elevated heart rate (178 bpm), tachypnea (RR 65), oxygen saturation of 92% on room air, retractions, head bobbing, and restlessness all point to respiratory distress.

The delayed capillary refill (>4 seconds) and inability to stay latched to the breast suggest dehydration, likely from poor oral intake and increased insensible fluid losses through tachypnea.

These interventions help improve oxygenation by clearing mucus obstructing the nasal passages (especially important for obligate nose-breathers like young infants) and providing supplemental oxygen.

Rationale for Incorrect Options:

Deep suctioning: Generally reserved for severe cases and requires provider order; may be too invasive initially.

Hunger: While hunger may cause fussiness, it is not a primary concern in this clinical picture.

Pain: Not supported by the current assessment findings; signs point more clearly to respiratory issues.

Correct Answer is ["C","D","E"]

Explanation

A. Delayed motor development is not a typical feature of cystic fibrosis, though respiratory and nutritional issues may impact physical development.

B. Cystic fibrosis is autosomal recessive, not dominant, meaning both parents must carry the gene for the child to inherit the disease.

C. Pancreatic enzyme insufficiency occurs in cystic fibrosis, leading to poor digestion and malabsorption.

D. Thick, sticky mucus in the lungs and digestive tract is a hallmark of cystic fibrosis, causing respiratory and gastrointestinal issues.

E. Increased risk for lung infections is common due to mucus buildup in the lungs, which provides a breeding ground for bacteria.

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