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 C
Explanation
Choice A rationale
Vomiting is not a common side effect of epidural anesthesia. Nausea can occur, but it is usually associated with the opioids used in the epidural, not the epidural itself.
Choice B rationale
Tachycardia, or a rapid heart rate, is not a typical side effect of epidural anesthesia. In fact, an epidural can sometimes cause a drop in heart rate, known as bradycardia.
Choice C rationale
Hypotension, or low blood pressure, is a common side effect of epidural anesthesia. The medication used in the epidural can cause blood vessels to relax, which can lower blood pressure.
Choice D rationale
Respiratory depression is not a common side effect of epidural anesthesia. The medication used in an epidural primarily affects the nerves in the lower body, so it does not typically impact breathing. Digoxin Digoxin Explore
Correct Answer is A
Explanation
Choice A rationale
The nurse should reassure the patient by informing her about the hospital’s capabilities to handle such situations. The neonatal unit in the hospital is equipped to handle emergencies and care for preterm babies. This response is factual and directly addresses the patient’s concern about the baby’s well-being.
Choice B rationale
While it’s true that everyone worries about their baby when they’re in labor, this response doesn’t directly address the patient’s concern about the baby’s health and well-being. It’s more of a general statement and doesn’t provide the reassurance the patient is seeking.
Choice C rationale
This response acknowledges the patient’s feelings, which is an important aspect of patient care. However, it doesn’t provide any information or reassurance about the baby’s health. The patient is specifically asking about the baby’s well-being, so the response should focus on that.
Choice D rationale
This response could be misleading. While it’s true that the chances of survival for preterm babies improve with each passing week, it’s not guaranteed that a baby born at 32 weeks will be fine. It’s important to provide accurate information and not give false reassurances.
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