A nurse is caring for an infant who has tetralogy of Fallot. The infant is crying and is experiencing a hypercyanotic spell. Which of the following actions should the nurse take first?
Administer morphine subcutaneously.
Apply a face mask supplying 100% oxygen.
Attempt to calm and soothe the child.
Place the infant in a knee-chest position.
The Correct Answer is B
Choice A rationale:
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
Choice B rationale:
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
Choice C rationale:
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
Choice D rationale:
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Rhinorrhea is not a common adverse effect of baclofen.
Choice B rationale:
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
Choice C rationale:
Tachycardia is not a common adverse effect of baclofen.
Choice D rationale:
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
Correct Answer is B
Explanation
Choice A rationale
Omeprazole is a proton pump inhibitor used to reduce stomach acid production and is not typically used for treating bloody stools in inflammatory bowel disease.
Choice B rationale:
Infliximab is used to treat inflammatory bowel disease and can help manage symptoms such as bloody stools by suppressing the inflammatory response.
Choice C rationale:
Ondansetron is an antiemetic used for nausea and vomiting, not related to bloody stools.
Choice D rationale:
Metoclopramide is used to treat nausea, vomiting, and gastrointestinal motility disorders, not specifically indicated for bloody stools.
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