The nurse is caring for a child diagnosed with Tetralogy of Fallot who has positioned themselves in a squatting position. The nurse understands this position:

Increases the return of venous blood back to the heart.

Is a common position when a child is tachycardic.

Decreases arterial blood flow away from the heart.

Increases the workload of the heart.

Answer and Explanation

The Correct Answer is A

Choice A reason: Squatting increases the return of venous blood back to the heart by compressing the large veins in the legs and abdomen. This position helps increase systemic vascular resistance, which in turn increases the blood flow to the lungs and improves oxygenation. Children with Tetralogy of Fallot often instinctively squat to relieve cyanotic spells, as it helps reduce the severity of symptoms by temporarily improving circulation.

Choice B reason: While a child might experience tachycardia during a cyanotic spell, squatting is not a position specifically associated with tachycardia. The primary purpose of squatting in children with Tetralogy of Fallot is to improve venous return and systemic vascular resistance, not to address tachycardia directly.

Choice C reason: Squatting does not decrease arterial blood flow away from the heart. Instead, it helps increase systemic vascular resistance, which improves pulmonary blood flow and oxygenation. This position assists in temporarily mitigating the effects of the heart defect by improving circulation.

Choice D reason: Squatting actually helps alleviate some of the workload on the heart by improving systemic vascular resistance and enhancing blood flow to the lungs. It is a compensatory mechanism that children with Tetralogy of Fallot use instinctively to manage cyanotic spells, and it does not increase the workload of the heart.

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Correct Answer is B

Explanation

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

A. Ibuprofen. B. Vigorous massage. C. Cold compress. D. Formula supplements. E. Lactation consult.

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

Explanation

Choice A reason: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help relieve pain and reduce inflammation associated with cracked nipples and engorged breasts. It is commonly used to manage postpartum pain and can provide significant relief, making breastfeeding more comfortable for the patient.

Choice B reason: Vigorous massage is not recommended for engorged breasts as it can cause additional pain and may worsen the condition. Gentle massage may help in some cases, but vigorous massage can lead to tissue damage and further discomfort. The focus should be on gentle techniques to manage engorgement.

Choice C reason: Cold compresses are effective in reducing swelling and providing pain relief for engorged breasts. Applying cold packs to the breasts can help reduce inflammation and soothe discomfort, making it easier for the patient to breastfeed. Cold therapy is a simple and non-invasive method to manage engorgement and related symptoms.

Choice D reason: Formula supplements are generally not recommended as a first-line intervention for breastfeeding issues, especially when the goal is to promote exclusive breastfeeding. Introducing formula can interfere with milk supply and the breastfeeding process. Instead, addressing the underlying issues such as latch and nipple care is more appropriate.

Choice E reason: A lactation consult is an essential intervention for a patient experiencing breastfeeding difficulties. Lactation consultants are trained to provide support and guidance on breastfeeding techniques, including how to achieve a proper latch, manage engorgement, and care for cracked nipples. Their expertise can significantly improve the breastfeeding experience and help resolve common issues.

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The nurse is caring for a child diagnosed with Tetralogy of Fallot who has positioned themselves in a squatting position. The nurse understands this position:

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Naxlex Comprehensive Predictor Exams

The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Correct Answer is B

Explanation

The nurse is caring for a patient three days postpartum who is exclusively breastfeeding. Upon assessment, the patient has cracked nipples, engorged breasts, and a painful latch. What will the nurse include in the patient's plan of care? Select all that apply.

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

Explanation

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