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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Disposing of the child's brushes, combs, and other hair accessories can be a good practice to prevent reinfestation, but it is not the primary instruction to provide in this case.
B. Taking the child to a hair salon for a shampoo and a shorter haircut is not a necessary or recommended treatment for head lice.
C. Wash the child's bed linens and clothing in hot soapy water.
When a child has head lice, it's important to take measures to prevent the spread of lice to others and to eliminate any potential sources of reinfestation. Washing the child's bed linens and clothing in hot, soapy water is an essential step in this process to kill any lice or nits (lice eggs) that may be present on these items.
D. Rewashing the child's hair following a 24-hour isolation period is not the standard approach for treating head lice with permethrin shampoo. It is important to follow the specific instructions provided with the product and to avoid overuse or misuse of the treatment.
The primary focus should be on treating the child's hair with the appropriate lice treatment (permethrin shampoo) as directed and taking preventive measures such as washing bed linens and clothing to reduce the risk of reinfestation.
Correct Answer is C
Explanation
A. Weight loss can occur in acute glomerulonephritis due to decreased appetite and fluid imbalances, but it is not as immediately concerning as low blood pressure.
B. A positive rapid strep test of the oropharynx suggests streptococcal infection, which can be a cause of acute glomerulonephritis. It's important to report this finding to the healthcare provider, but the low blood pressure is of more immediate concern.
C. Blood pressure 88/50 mm Hg.
Acute glomerulonephritis can lead to various signs and symptoms, including fatigue, facial puffiness, decreased appetite, and dark urine, due to the presence of blood and protein in the urine. However, the drop in blood pressure (88/50 mm Hg) is a significant finding that may suggest potential complications or worsening renal function. Low blood pressure can result from fluid shifts, reduced circulating blood volume, and decreased cardiac output in acute glomerulonephritis. It should be reported to the healthcare provider for further evaluation and management.
D. A maculopapular rash over the trunk of the body is not a typical finding associated with acute glomerulonephritis. While it may be significant for other reasons, it may not be directly related to the child's kidney condition.
Monitoring and addressing blood pressure changes is a crucial aspect of managing acute glomerulonephritis, and the healthcare provider should be informed promptly to assess and address this issue.
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