An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?
Administer oxygen.
Place the infant in Trendelenburg position.
Draw blood for a serum hemoglobin.
Place the infant in knee-chest position.
Administer morphine as ordered.
Correct Answer : A,D,E
Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.
Correct Answer is A
Explanation
Choice A reason: Allowing parents to hold their infant is a compassionate act that acknowledges their need for closure and can help them begin the grieving process.
Choice B reason: Interviewing parents to determine the cause of the incident is not considered supportive care; it may be part of an investigation but does not provide comfort.
Choice C reason: Providing mementos can be a cherished way for parents to remember their infant and can offer some solace during a difficult time.
Choice D reason: Advising parents about the necessity of an autopsy is not supportive care; it is a medical decision that should be discussed with sensitivity to the parents' feelings and needs. Autopsies can be important for understanding SIDS and preventing future occurrences.
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