A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Administer morphine sulfate to help alleviate pain and anxiety.

Provide supplemental oxygen via nasal cannula.

Offer the infant a pacifier to calm down.

Place the infant in a knee to chest position.

Answer and Explanation

The Correct Answer is D

A.   While morphine can help to relieve anxiety and pain, it does not address the underlying cause of a hypercyanotic spell, which is the right-to-left shunting. The first step should be positioning the infant properly.
B.   Although oxygen is helpful, it will not be as effective as using the knee-to-chest position to alleviate the underlying circulatory issue causing the hypercyanotic spell.
C.   While comforting the child is important, a pacifier will not help in alleviating the hypercyanotic spell and is not the primary intervention in this emergency situation.
D.   In a hypercyanotic spell, the priority is to increase systemic vascular resistance to decrease the right- to-left shunting of blood. The knee-to-chest position is effective for this, as it increases the resistance in the lower extremities, helping to improve oxygenation.

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Correct Answer is B

Explanation

A. Redness can occur with skin irritation or infection, but it is not the defining symptom of scabies. Pruritus (itching) is more characteristic.
B. The hallmark symptom of scabies is intense itching (pruritus), particularly at night, due to an allergic reaction to the mite infestation in the skin.
C. Edema is not a primary symptom of scabies. It may occur as a result of a secondary infection, but it is not typically associated with the infestation itself.
D. Maceration refers to the softening or breakdown of the skin from excessive moisture, which could happen if the skin is scratched excessively. However, maceration is not a hallmark symptom of scabies.

A. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management B. Restriction of weight-bearing activities to prevent further damage C. Prescription of crutches for mobility assistance D. Application of ice packs to reduce inflammation E. Immediate referral to an orthopedic specialist for evaluation F. Application of a heat pack to relieve muscle tension

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

Explanation

A. NSAIDs may help with pain management, but they are not the primary treatment for SCFE.
B. Restricting weight-bearing activities is crucial to prevent further damage and complications to the affected hip joint.
C. Crutches may be prescribed to assist with mobility and prevent weight-bearing on the affected hip.
D. Ice packs may reduce inflammation but are secondary to more important interventions like weight restriction and orthopedic referral.
E. Immediate referral to an orthopedic specialist is necessary for appropriate diagnosis and management, including possible surgery.
F. Heat packs are not recommended for SCFE because they could increase blood flow and swelling in the affected area.

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A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry. What is the priority nursing action for this Infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking care of a child with scables. Which primary clinical manifestation should the nurse expect to assess with this disease?

Correct Answer is B

Explanation

A Nurse is caring for a child with Slipped Capital Femoral Epiphysis (SCFE). Which interventions should be prioritized for a child with SCFE? SELECT ALL THAT APPLY.

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

Explanation

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