During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?

Evaluate infant for failure to thrive (FTT).

Auscultate heart and lungs while infant is held.

Stimulate the infant to cry to produce cyanosis.

Obtain a 12-lead electrocardiogram.

Answer and Explanation

The Correct Answer is B

A. Evaluating the infant for failure to thrive (FTT) is not the most appropriate initial intervention in this case. FTT is a long-term growth issue, and the immediate concern is the infant's current symptoms and cardiac status.

B. Auscultate heart and lungs while the infant is held.

Tetralogy of Fallot (TOF) is a congenital heart defect that includes four specific cardiac abnormalities, and it often requires surgical correction in infancy. When an infant with a history of TOF surgery presents with symptoms such as rapid breathing, feeding difficulties, and fatigue, it may raise concerns about potential cardiac issues or complications.

The most appropriate initial intervention is to auscultate the infant's heart and lungs while the infant is held to assess for any abnormal heart sounds or signs of respiratory distress. Auscultation can provide important information about the infant's cardiac and respiratory status. This assessment will help determine if there are any immediate concerns related to the infant's cardiac condition.

C. Stimulating the infant to cry to produce cyanosis is not a recommended or appropriate intervention. Cyanosis is a sign of inadequate oxygenation and should not be induced in a child.

D. Obtaining a 12-lead electrocardiogram may be indicated if there are significant concerns about the infant's cardiac status, but auscultation should be performed first to assess the immediate condition. An electrocardiogram is a diagnostic tool and would be ordered as a follow-up assessment if needed.

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Correct Answer is A

Explanation

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

A. Rice. B. Oats. C. Rye. D. Barley.

Correct Answer is A

Explanation

Celiac disease is an autoimmune disorder in which individuals are unable to tolerate gluten, a protein found in wheat, barley, and rye. Therefore, foods containing wheat, barley, and rye should be avoided by individuals with celiac disease. The list of allowed foods should primarily consist of gluten-free options.

A. Rice is naturally gluten-free and is safe for individuals with celiac disease to consume.

B. Oats can be included in the diet of individuals with celiac disease, but they must be specifically labeled as "gluten-free oats." Regular oats can be cross-contaminated with gluten during processing, so it's important to choose certified gluten-free oats to avoid potential issues.

C. Rye contains gluten and should be avoided by individuals with celiac disease.

D. Barley contains gluten and should be avoided by individuals with celiac disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

Correct Answer is A

Explanation

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrates an understanding of the education? (Select all that apply.)

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse Implement to ensure the child's cooperation?

Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.