An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
Prepare family for imminent death
Place the child in the knee-chest position
Assess for neurologic defects
Begin cardiopulmonary resuscitation
The Correct Answer is B
Hypercyanotic spells, also known as "Tet spells," can occur in infants with congenital heart defects, particularly tetralogy of Fallot. During these spells, there is a sudden decrease in oxygen saturation, leading to cyanosis (blueness) of the infant's skin and lips, as well as respiratory distress and possible loss of consciousness.
The knee-chest position is a specific technique used to manage hypercyanotic spells. Placing the child in this position helps improve oxygenation by increasing systemic vascular resistance and reducing the degree of right-to-left shunting of blood in the heart. It also increases venous return to the heart, which can help improve cardiac output.
Now, let's discuss why the other options are incorrect:
A. Prepare family for imminent death: This is not the priority action. While hypercyanotic spells can be life-threatening, the immediate focus should be on managing the spell to improve oxygenation and prevent further deterioration. Preparing the family for death should only be considered if resuscitation measures fail, which is not the first-line intervention.
C. Assess for neurologic defects: Assessing for neurologic defects is important but not the immediate priority during a hypercyanotic spell. The primary concern at this moment is addressing cyanosis and respiratory distress to ensure the infant receives adequate oxygen.
D. Begin cardiopulmonary resuscitation: Initiating CPR is not the initial priority during a hypercyanotic spell. CPR would be indicated if the infant's condition deteriorates to the point of cardiac arrest, but it should not be the first step. Placing the child in the knee-chest position is a non-invasive intervention that should be attempted before considering CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
For a family with a child diagnosed with obesity and hyperlipidemia, the recommended actions in the educational pamphlet should focus on promoting a healthy lifestyle and managing these conditions effectively. The most appropriate recommendations are:
A. Children-specific heart-healthy diet: Emphasize the importance of a balanced and heart-healthy diet for the child. Include information on portion control, reducing high-fat and high-sugar foods, increasing fruit and vegetable intake, and incorporating whole grains. Encourage families to work with a registered dietitian or nutritionist for personalized dietary guidance.
C. Nutrition guidance from a pediatric specialist: Recommend seeking guidance from a pediatrician or pediatric specialist with expertise in nutrition to develop a personalized nutrition plan for the child. Individualized guidance can help address specific dietary needs and concerns related to obesity and hyperlipidemia.
In contrast, the following options should not be included:
B. Start on statin medication first: Statin medications are typically not the first-line treatment for children with hyperlipidemia, especially if lifestyle modifications can effectively manage the condition. Medication use in children is typically reserved for cases where lifestyle changes alone are insufficient or when there are other medical considerations.
D. Encourage more than 4 hours of screen time per day: Encouraging excessive screen time is not recommended, as it can contribute to a sedentary lifestyle, which is often associated with obesity. Limiting screen time and promoting physical activity are important components of managing obesity.
E. Exercise for at least 3 hours daily: While physical activity is important for managing obesity, recommending over 3 hours of exercise daily may not be realistic or sustainable for most children. Instead, it's better to encourage regular physical activity, such as at least 60 minutes of moderate to vigorous activity daily, as recommended by guidelines for children.
Overall, the focus should be on adopting a healthy lifestyle, including a balanced diet and appropriate physical activity, under the guidance of healthcare professionals, to manage obesity and hyperlipidemia in children.
Correct Answer is B
Explanation
When obtaining the history of a child with suspected rheumatic fever, the nurse should consider the following information to be most significant:
B. A recent episode of pharyngitis.
Explanation:
Rheumatic fever often follows an untreated or inadequately treated streptococcal pharyngitis (strep throat) infection caused by Group A Streptococcus bacteria. Therefore, a recent episode of pharyngitis is a key piece of information in the context of rheumatic fever. It is important to assess whether the child had a sore throat, fever, and other symptoms of streptococcal infection that may have triggered the development of rheumatic fever.
While the other symptoms (vomiting, lack of interest in food, fever) may be important for the overall assessment and management of the child, they are not as directly associated with the development of rheumatic fever as a recent episode of pharyngitis caused by Group A Streptococcus. Rheumatic fever is an autoimmune response to untreated streptococcal infection, and its diagnosis is often linked to the presence of preceding streptococcal pharyngitis.
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