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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Correct Answer is D
Explanation
Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.
Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.
Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.
Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
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