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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. If an orogastric tube fails to pass, it may indicate a blockage or abnormal connection, such as a tracheoesophageal fistula.
Choice B reason: Low birth weight can be associated with many conditions and is not specific to TEF.
Choice C reason: TEF is not typically visible without special imaging or procedures; it cannot be visually identified at delivery.
Choice D reason: Dry mouth and nares with little to no oral secretions could indicate other conditions and are not specific to TEF. TEF often presents with excessive oral secretions.

A. Pneumonia B. Active pulmonary tuberculosis C. RSV D. Croup

Correct Answer is C

Explanation

Choice A reason: Pneumonia could present with these symptoms, but it is less likely in this case due to the specific combination of symptoms described.
Choice B reason: Active pulmonary tuberculosis is less common in infants and does not typically present with these acute symptoms.
Choice C reason: This is the correct choice. The symptoms described are characteristic of Respiratory Syncytial Virus (RSV), especially in infants.
Choice D reason: Croup could cause some of these symptoms, but it is more commonly associated with a distinctive barking cough and stridor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What clinical manifestation in a newborn would cause a nurse to suspect the diagnosis of tracheoesophageal fistula (TEF)?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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