The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:
Place him in knee-chest position
Have him lie prone, being sure he can breathe easily
Have him lie supine with the head turned to one side
Place him in semi-fowler's position in an infant seat
The Correct Answer is A
A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.
B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.
C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.
D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A storybook may provide comfort and information but is less interactive in helping the child process the experience of injections.
B. Playing in the playroom is beneficial for normalizing hospital stays but does not directly address the child’s distress regarding injections.
C. A video game can be a good distraction but does not provide therapeutic engagement with the fear or anxiety related to injections.
D. Allowing the child to play with a needleless syringe and a doll is therapeutic as it gives the child a sense of control and understanding of the injection process, helping to reduce fear and anxiety.
Correct Answer is A
Explanation
A. Acetaminophen is appropriate for managing mild discomfort post-procedure.
B. Tub baths are generally avoided for the first few days to prevent infection at the catheterization site; sponge baths are preferred.
C. Keeping the child home for 1 week might be excessive; follow the healthcare provider's specific instructions regarding activity and school return.
D. Clear liquids are typically offered as tolerated, but the primary concern post-procedure is monitoring the insertion site and ensuring the child rests adequately.
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