The nurse is giving instructions to parents of a 4-month-old infant with tetralogy of Fallot. Important teaching points should include:
If the infant becomes blue and is breathing deeply, put her in the knee-chest position.
If the infant becomes blue and is breathing deeply, put her in the Trendelenburg position.
Feed the infant every 2 hours around the clock.
Add rice cereal to her formula to increase her calories.
The Correct Answer is A
Choice A reason: This is the correct statement, as the knee-chest position can help reduce the cyanosis and hypoxia in infants with tetralogy of Fallot. This position increases the systemic vascular resistance and decreases the right-to-left shunting of blood, improving the pulmonary blood flow and oxygenation¹².
Choice B reason: This is not a correct statement, as the Trendelenburg position can worsen the cyanosis and hypoxia in infants with tetralogy of Fallot. This position decreases the systemic vascular resistance and increases the right-to-left shunting of blood, reducing the pulmonary blood flow and oxygenation¹².
Choice C reason: This is not a correct statement, as feeding the infant every 2 hours around the clock can cause overfeeding and fatigue in infants with tetralogy of Fallot. These infants may have poor appetite and weight gain due to their cardiac condition, and they may need frequent rest periods during feeding. Feeding the infant on demand or every 3 to 4 hours may be more appropriate¹³.
Choice D reason: This is not a correct statement, as adding rice cereal to the formula can increase the risk of aspiration and choking in infants with tetralogy of Fallot. These infants may have difficulty swallowing and coordinating their breathing, and they may need a thin and easily digestible formula. Adding rice cereal to the formula may also increase the caloric density and volume, which can cause overfeeding and fatigue¹³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct cause, as varicella is a viral infection that causes a blister-like rash all over the body, not just in the diaper area. Varicella also causes fever, headache, and malaise.
Choice B reason: This is the correct cause, as Candida albicans is a type of fungus that can cause diaper rash, especially after antibiotic use. Antibiotics can disrupt the normal flora of the skin and allow the fungus to grow. Candida albicans causes red, inflamed skin with small, raised bumps around the edges.
Choice C reason: This is not the correct cause, as impetigo is a bacterial infection that causes honey-colored crusts on the skin, usually around the mouth and nose. Impetigo is contagious and can spread to other parts of the body or other people.
Choice D reason: This is not the correct cause, as bacterial infection is too vague and nonspecific. Bacterial infection can cause different types of skin rashes, depending on the type and location of the bacteria. Bacterial infection may also cause other symptoms, such as fever, pus, or swelling.
Correct Answer is A
Explanation
Choice A reason: Suctioning the mouth and nasopharyngeal passages is the most important priority for airway care after a cleft palate repair. This is because the infant may have blood, mucus, or secretions in the mouth or nose that can obstruct the airway and cause breathing difficulties. Suctioning can help clear the airway and prevent aspiration, infection, or hypoxia.
Choice B reason: Cleaning the suture line with normal saline is an important part of wound care after a cleft palate repair, but it is not the most important priority for airway care. Cleaning the suture line can help prevent infection, promote healing, and reduce scarring. However, it should be done gently and carefully, as not to disturb the sutures or cause bleeding.
Choice C reason: Elevating the head of the bed 30 degrees is a helpful measure to facilitate breathing and drainage after a cleft palate repair, but it is not the most important priority for airway care. Elevating the head of the bed can help reduce swelling, congestion, and pressure on the surgical site. However, it should be done with caution, as not to cause neck flexion or extension that may compromise the airway.
Choice D reason: Giving IV morphine for pain is a necessary intervention to provide comfort and analgesia after a cleft palate repair, but it is not the most important priority for airway care. Giving IV morphine can help relieve the pain and distress that the infant may experience after the surgery. However, it should be given with close monitoring, as it may cause respiratory depression, sedation, or hypotension.
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