A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight.
What actions should the nurse plan to take? (Select all that apply.)
Administer morphine via IV bolus.
Position the infant in a knee-chest position.
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Request a prescription for a diuretic.
Administer an additional dose of digoxin.
Prepare to assist with the insertion of a chest tube.
Correct Answer : B,E
Choice A rationale
Administering morphine via IV bolus is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine can be used in certain situations to manage pain or anxiety, it is not a specific treatment for the symptoms associated with Tetralogy of Fallot.
Choice B rationale
Positioning the infant in a knee-chest position can be beneficial for infants with Tetralogy of Fallot. This position can help increase blood flow to the lungs, which can improve oxygenation and alleviate symptoms.
Choice C rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a specific action for an infant diagnosed with Tetralogy of Fallot. While suctioning can be used to clear the airway in certain situations, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Choice D rationale
Requesting a prescription for a diuretic is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. Diuretics are often used to manage fluid balance in the body, but they do not address the underlying heart defects associated with Tetralogy of Fallot.
Choice E rationale
Administering an additional dose of digoxin can be beneficial for infants with Tetralogy of Fallot. Digoxin is a medication that helps strengthen the heart muscle, enabling it to pump more efficiently. This can help manage symptoms associated with Tetralogy of Fallot.
Choice F rationale
Preparing to assist with the insertion of a chest tube is not a specific action for an infant diagnosed with Tetralogy of Fallot. While a chest tube can be used to manage certain respiratory conditions, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Practicing Kegel exercises is a common recommendation for postpartum women experiencing urinary incontinence. Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum. Strengthening these muscles can help control urinary incontinence.
Choice B rationale
Abdominal crunches are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice C rationale
Similar to abdominal crunches, sit-ups are not typically recommended for postpartum women, especially those who have had a cesarean birth. These exercises can strain the abdominal muscles and may interfere with the healing process.
Choice D rationale
While pelvic tilt exercises can be beneficial for postpartum women, they are not specifically targeted at improving urinary incontinence.
Correct Answer is B
Explanation
Choice A rationale
While reduced fetal oxygen supply can occur with hypertonic contractions and inadequate uterine relaxation, it’s not the primary adverse effect. The main concern is the impact on the progress of labor.
Choice B rationale
This is the correct answer. Inadequate uterine relaxation between hypertonic contractions can delay cervical dilation, slowing the progress of labor.
Choice C rationale
Prolonged labor is not typically associated with hypertonic contractions and inadequate uterine relaxation. In fact, these conditions can lead to a more rapid labor.
Choice D rationale
Increased maternal stress can occur with any labor complication, but it’s not the primary adverse effect of hypertonic contractions and inadequate uterine relaxation.
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