A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
Overriding aorta
Pulmonary stenosis
Left ventricular hypertrophy
Ventricular septal defect
The Correct Answer is C
A. Overriding aorta: In Tetralogy of Fallot, the aorta is positioned over the ventricular septal defect (VSD), rather than solely over the left ventricle as it would be in a normal heart. This is called overriding aorta, which allows blood from both the right and left ventricles to enter the aorta.
B. Pulmonary stenosis: This is a critical component of Tetralogy of Fallot. Pulmonary stenosis refers to narrowing of the pulmonary valve or the area just below it, which restricts blood flow from the right ventricle to the pulmonary artery. This results in decreased blood flow to the lungs for oxygenation.
C. Left ventricular hypertrophy: This choice is not typically associated with Tetralogy of Fallot. Left ventricular hypertrophy refers to an enlargement or thickening of the muscular wall of the left ventricle of the heart. It is often seen in conditions where the left ventricle has to work harder to pump blood, such as in hypertension or aortic stenosis, but it is not a characteristic feature of Tetralogy of Fallot.
D. Ventricular septal defect: This defect is one of the four components of Tetralogy of Fallot. A ventricular septal defect (VSD) is a hole in the septum, the muscular wall that separates the left and right ventricles of the heart. In Tetralogy of Fallot, the VSD allows oxygen-poor blood from the right ventricle to flow directly into the left ventricle and out to the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Restrain the toddler for 1 hr after the procedure:
This choice involves restraining the toddler for a period of time after the lumbar puncture procedure. However, restraining a toddler for such a prolonged period is not typically necessary and may cause distress and discomfort to the child. Moreover, prolonged restraint is not recommended as it can hinder the child's mobility and may lead to emotional distress.
B. Swaddle the toddler in a warm blanket:
Swaddling a toddler in a warm blanket may provide comfort, but it is not directly relevant to the lumbar puncture procedure itself. While comfort measures are important for overall patient care, they should not replace or interfere with the specific positioning requirements for medical procedures like a lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position:
This choice involves having another nurse assist in holding the toddler in a prone (face-down) position during the lumbar puncture procedure. However, the prone position is not typically used for lumbar punctures in toddlers. Placing the toddler in a prone position might make the procedure more challenging and less safe for both the child and the healthcare provider.
D. Place the toddler in a side-lying knee-chest position:
Placing the toddler in a side-lying knee-chest position is the correct action for a lumbar puncture procedure in a toddler. This position maximizes the space between the vertebrae, making it easier for the healthcare provider to access the lumbar area safely and accurately. It also helps minimize the risk of injury and discomfort for the toddler during the procedure. Therefore, this choice is the most appropriate for ensuring the success and safety of the lumbar puncture procedure.
Correct Answer is B
Explanation
A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.
B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.
C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.
D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.
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