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 ["B","F","G","H"]
Explanation
A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.
C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.
D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.
E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.
The assessment findings that suggest stabilization include:
A blood pressure within the normal range (126/76 mm Hg).
A heart rate within the normal range (72 beats/minute).
Oxygen saturation of 98% on room air, indicating adequate oxygenation.
A normal body temperature (98.9°F or 37.1°C orally).
These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.
Correct Answer is D
Explanation
A. Encourage the parents to rest when possible.While ensuring that parents get rest is important for overall family well-being, this intervention does not directly address the child's immediate symptoms.
B. Apply lotion to hands and feet.Applying lotion can help soothe the discomfort associated with skin peeling. However, this intervention is more supportive and addresses a later concern. It does not directly alleviate the child's irritability or refusal to eat.
C. Make a list of foods that the child likes.This intervention focuses on improving the child's nutritional intake by offering familiar foods. However, if the child is irritable and overstimulated, their refusal to eat may be due to discomfort or distress. Addressing the irritability first may improve their willingness to eat.
D. Place the child in a quiet environment.Children with Kawasaki disease often experience irritability due to discomfort, fever, and the overall systemic effects of the illness. Creating a quiet environment helps reduce sensory stimulation, which can soothe the child and decrease irritability.
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