Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Perform nasopharyngeal suctioning for a maximum of 5 seconds.

Position the infant in a knee-chest position.

Administer morphine via IV bolus.

Provide 100% oxygen by face mask.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a recommended action for an infant diagnosed with Tetralogy of Fallot. This procedure is typically used to clear the airway in infants with respiratory distress, not heart conditions.
Choice B rationale
Positioning the infant in a knee-chest position can help increase blood flow to the lungs, which is beneficial for an infant with Tetralogy of Fallot. This condition involves a combination of heart defects that affect the normal flow of blood through the heart.
Choice C rationale
Administering morphine via IV bolus is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine is a powerful pain reliever, it is not typically used in the management of this condition.
Choice D rationale
Providing 100% oxygen by face mask is not a recommended action for an infant diagnosed with Tetralogy of Fallot. While supplemental oxygen can help increase the amount of oxygen in the blood, it does not address the underlying heart defects associated with this condition.

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Correct Answer is B

Explanation

Choice A rationale
Constipation is not typically associated with a sickle cell crisis. While it can occur due to dehydration, which can trigger a sickle cell crisis, it is not a primary symptom.
Choice B rationale
Pain is the most common symptom of a sickle cell crisis. When sickle-shaped cells block blood flow in the small blood vessels, it can cause severe pain. This pain can occur anywhere in the body, but it most often occurs in the chest, arms, and legs.
Choice C rationale
Bradycardia is not typically a symptom of a sickle cell crisis. Sickle cell crisis primarily affects the blood vessels and does not directly cause a slow heart rate.
Choice D rationale
While a high fever can occur in individuals with sickle cell disease, especially if there is an underlying infection, it is not a primary symptom of a sickle cell crisis.

A. Document this as an expected finding. B. Call the provider to further assess the newborn. C. Prepare the newborn for transport to the NICU. D. Ask another nurse to verify the heart rate.

Correct Answer is A

Explanation

Choice A rationale
A newborn’s heart rate normally varies between 120 and 160 beats per minute, but it can rise to 180 beats per minute when the infant is crying or drop as low as 80 to 90 beats per minute when in deep sleep. Therefore, an apical heart rate of 130/min is within the normal range for a newborn.
Choice B rationale
There is no need to call the provider for further assessment if the newborn’s heart rate is within the normal range.
Choice C rationale
Preparing the newborn for transport to the NICU is not necessary if the heart rate is within the normal range.
Choice D rationale
Asking another nurse to verify the heart rate is not necessary if the heart rate is within the normal range.

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Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is in sickle cell crisis. What findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?

Correct Answer is A

Explanation

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