A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect?

Select all that apply.

Bounding peripheral pulses

Cyanotic spells

Stridor

Anemia

heart murmur

Answer and Explanation

Correct Answer : B,E

A. "Bounding peripheral pulses." Bounding pulses are not characteristic of Tetralogy of Fallot. Instead, pulses may be normal or diminished, depending on the severity of the defect.
B. "Cyanotic spells." Tetralogy of Fallot causes decreased oxygenation, leading to periodic cyanotic episodes, particularly during crying or feeding ("tet spells").
C. "Stridor." Stridor is associated with upper airway obstructions, not cardiac defects like Tetralogy of Fallot.
D. "Anemia." Anemia is not a primary finding in Tetralogy of Fallot. Polycythemia (increased red blood cells) is more common due to chronic hypoxia.
E. "Heart murmur." A systolic murmur is common due to the pulmonary stenosis and ventricular septal defect associated with Tetralogy of Fallot.

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Correct Answer is A

Explanation

A. Accompany verbal instructions with visual references. Children with ADHD benefit from multimodal teaching strategies. Combining verbal instructions with visual aids helps reinforce understanding and keeps the child focused.
B. Vary the classroom routine to keep the children interested: Children with ADHD thrive on consistency; frequent changes in routine can increase confusion and distractibility.
C. Limit presentation of subjects of interest to the afternoons: This is not evidence-based. Children’s ability to focus varies throughout the day, and important content should not be restricted to a specific time.
D. Increase classroom assignments to stimulate learning: Increasing workload can overwhelm a child with ADHD, leading to frustration and reduced engagement.

A. Temperature 36.9°C (98.4° F) B. Heart rate 162/min C. Respiratory rate 28/min D. Also spits up after every feeding, sometimes forcefully E. Small, soft, midline bulge observed on abdomen between xyphoid process and umbilicus F. Weight 5,925 g (13 lb 1 oz). Parents report birth weight was 4,196 g (9 lb 4 oz)

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

Explanation

Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.

Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.

Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.

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A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect? Select all that apply.

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A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect?

Select all that apply.