A nurse is assisting in the care of an infant who has congenital heart disease.
Place the infant in a knee chest position
Administer morphine via IV bolus
Provide 100% oxygen by face mask
Request a prescription for a diuretic
Perform nasopharyngeal suctioning for a maximum of 5 seconds
Prepare to assist with the insertion of a chest tube
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Place the infant in a knee-chest position: Indicated: ☑️
The knee-chest position is commonly used during a "tet spell," which involves episodes of cyanosis due to decreased oxygen levels. This position increases systemic vascular resistance, which helps redirect blood flow to the lungs, improving oxygenation.
Administer morphine via IV bolus: Indicated: ☑️
Morphine is used to calm the infant, reduce respiratory effort, and decrease pulmonary vascular resistance. It can help in reducing the severity of the tet spell by promoting better oxygenation.
Provide 100% oxygen by face mask: Indicated: ☑️
Administering 100% oxygen can help increase the amount of oxygen in the blood and reduce the effects of hypoxia. Oxygen is a vasodilator and can reduce pulmonary resistance, making it easier for the infant to oxygenate blood.
Request a prescription for a diuretic: Contraindicated: ☑️
Diuretics are generally not indicated in the acute management of tet spells. While they are used in conditions with fluid overload, their use in this context is not beneficial and could potentially worsen the infant's condition by causing dehydration and further reducing blood volume.
Perform nasopharyngeal suctioning for a maximum of 5 seconds: Contraindicated: ☑️
Nasopharyngeal suctioning can be stressful for the infant and may worsen cyanosis or provoke a tet spell due to increased agitation and respiratory effort. It's typically not recommended unless there's a clear indication for airway clearance.
Prepare to assist with the insertion of a chest tube: Contraindicated: ☑️
Chest tube insertion is not a treatment for tet spells or ToF. It is usually indicated for pneumothorax or significant pleural effusions, which are not related to the acute cyanotic episodes seen in ToF. Preparing for this procedure would be inappropriate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restrain the toddler for 1 hr after the procedure: This is not necessary; the child should be monitored but not restrained.
B. Place the toddler in a side-lying, knee-chest position: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position: The prone position is not appropriate for a lumbar puncture as it does not provide proper spinal alignment.
D. Swaddle the toddler in a warm blanket: While comforting, it is not relevant to the procedure itself.
Correct Answer is B
Explanation
A. "I'll give him acetaminophen for the pain.": Acetaminophen is used for pain relief and fever reduction but does not address disease transmission. It does not prevent the spread of the streptococcal infection.
B. "I'll discard his toothbrush and buy another.": This is crucial because the streptococcal bacteria can remain on the toothbrush, leading to potential reinfection or spreading the bacteria to others. Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.
C. "I'll continue to encourage him to drink lots of fluids.": Staying hydrated is important for recovery, but it does not prevent the transmission of the infection.
D. "I'll take his temperature every 4 hours.": Monitoring temperature helps track the child’s condition but does not prevent the spread of the infection.
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