A nurse is caring for an infant who has congenital heart disease.
Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)
Administer morphine via IV bolus.
Prepare to assist with the insertion of a chest tube.
Place the infant in a knee-chest position.
Request a prescription for a diuretic.
Administer an additional dose of digoxin.
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Provide 100% oxygen by face mask.
Correct Answer : A,C,G
A. Administer morphine via IV bolus: Morphine is often used in infants with congenital heart defects, such as Tetralogy of Fallot, to reduce agitation, anxiety, and improve oxygenation by reducing systemic vascular resistance. However, this should be done cautiously, as it can decrease respiratory drive and should be administered per specific provider orders.
B. Prepare to assist with the insertion of a chest tube: A chest tube would not be indicated at this moment unless there is evidence of a pneumothorax, hemothorax, or pleural effusion. This scenario does not suggest these conditions.
C. Place the infant in a knee-chest position: This is a classic intervention for infants with Tetralogy of Fallot during a hypercyanotic spell. The knee-chest position increases systemic vascular resistance and reduces the right-to-left shunting of blood, helping to improve oxygenation and reduce cyanosis.
D. Request a prescription for a diuretic: Diuretics are commonly used in infants with congenital heart disease, including Tetralogy of Fallot, to manage fluid retention. This is important for controlling symptoms of heart failure, which may exacerbate cyanosis and respiratory distress.
E. Administer an additional dose of digoxin: While digoxin is used to manage heart failure in infants with congenital heart defects, there is no indication that the infant is in heart failure at this moment, and additional digoxin should only be administered with a provider's order, based on specific clinical needs.
F. Perform nasopharyngeal suctioning for a maximum of 5 seconds: Suctioning should only be performed if the infant is visibly obstructed or struggling with airway clearance. Prolonged or unnecessary suctioning could lead to further agitation and hypoxia in this infant.
G. Provide 100% oxygen by face mask: While oxygen alone isn't always fully effective in tet spells due to the shunting of blood, it's still an important intervention to maximize available oxygen.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fear of bodily injury is a concern but may not be as prominent as separation anxiety, particularly in younger children.
B. Fear of pain is significant but often secondary to the anxiety of being separated from parents.
C. Separation anxiety is the most prominent stressor for toddlers and preschoolers, as they struggle with being away from their caregivers.
D. Loss of control can contribute to stress but is more relevant in older children who understand their environment more clearly.
Correct Answer is A
Explanation
A. Clinicians should be involved in discussions about the child’s prognosis to ensure that the family receives clear, compassionate information for decision-making.
B. Palliative care can and should be introduced earlier in the course of the illness, not just when the child is expected to live less than 6 months.
C. Parents expressing hope for survival do not necessarily reject palliative care. Palliative care can focus on comfort and quality of life even when there is still hope for recovery.
D. Palliative care should be integrated with curative care, as it can improve the quality of life while still pursuing treatment options.
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