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 D
Explanation
A. Discontinue the ointment once drainage resolves.The ophthalmic antiinfective ointment should be used for the full prescribed duration, even if symptoms improve, to ensure the infection is completely treated and to prevent recurrence or resistance.
B. Remove secretions by wiping toward the opposite eye.Secretions should be removed by wiping away from the eye, from the inner canthus (near the nose) outward, to prevent spreading infection to the unaffected eye.
C. Use a disposable moist wipe to remove eye crusts.While it is important to keep the eye clean, the primary discharge instruction in this context should focus on the expected side effect of blurry vision.
D. Prepare child for blurry vision after ointment application:Ophthalmic antiinfective ointments can cause temporary blurry vision due to their consistency. Caregivers should be informed about this expected effect and reassured that it is temporary. This helps manage expectations and ensures adherence to the treatment plan.
Correct Answer is B
Explanation
The most important information for the nurse to provide to the mother of an 11-year-old boy with juvenile idiopathic arthritis is B.
Explanation:
A. Encouraging quiet activities such as watching television as a pain distracter can be helpful, but it should be used in conjunction with appropriate pain management strategies.
B Giving pain medication around the clock helps control the pain.
Children with juvenile idiopathic arthritis often experience chronic pain and inflammation. It's important for the mother to understand that, in some cases, simply taking pain medication when the child is in severe pain may not be the most effective approach. Pain management in chronic conditions like arthritis typically involves a more proactive and regular approach.
C. While hot baths can be soothing and offer some pain relief, they may not provide sufficient pain control for chronic conditions like juvenile idiopathic arthritis. Using hot baths can be a complementary approach but may not replace the need for pain medication.
D. Encouraging the child to rest when experiencing pain is important, but it should also be combined with appropriate pain management. Rest alone may not provide adequate pain relief for a child with arthritis.
The key information here is that giving pain medication around the clock, under the guidance of a healthcare provider, can help provide continuous pain control and improve the child's quality of life. Parents should work closely with the healthcare team to develop a comprehensive pain management plan that may include a combination of medications, physical therapy, and lifestyle modifications.
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