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 ["C","D"]
Explanation
A. Keep the infant in a side-lying position.
This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.
B. Remove elbow restraints while the infant is sleeping.
Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.
C. Administer pain medication around the clock for the first 72 hours.
This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.
D. Feed the infant half-strength formula for the first 48 hours.
This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.
Correct Answer is ["B","D"]
Explanation
A. Cranberry juice
Cranberry juice may be too acidic and could irritate the surgical site. It's best to avoid acidic beverages immediately following a tonsillectomy.
B. Ice-cream
This option is suitable. Ice-cream is cold and soothing, and it can help numb the throat, providing relief from discomfort after a tonsillectomy. However, it's essential to ensure that the ice-cream is not too cold to avoid causing discomfort.
C. Hot tea
Hot tea is not recommended immediately following a tonsillectomy. Hot liquids can irritate the surgical site and may cause discomfort. It's best to avoid hot beverages until the throat has had time to heal.
D. Italian ice
Italian ice is a frozen dessert similar to a slushy, and it can be a suitable option after a tonsillectomy. Like ice-cream, Italian ice is cold and can help numb the throat, providing relief from discomfort.
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