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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Postpartum depression is characterized by severe mood swings, crying too much, difficulty bonding with the baby, withdrawing from family and friends, loss of appetite or eating much more than usual, inability to sleep or sleeping too much, overwhelming tiredness or loss of energy. While some of these symptoms overlap with the ones mentioned in the question, postpartum depression is usually more severe and lasts longer.
Choice B rationale
The letting-go phase is the final phase of maternal adjustment during which the mother moves forward from her existing role to take on a new one as a parent. This phase is characterized by reestablishment of relationships with others, resumption of sexual intimacy, resolution of physical symptoms, and attainment of a new normal. The symptoms mentioned in the question do not align with this phase.
Choice C rationale
Postpartum psychosis is a rare but serious mental health illness that can affect a woman soon after she has a baby. Symptoms can include hallucinations, delusions, a manic mood, a low mood, loss of inhibitions, restlessness, and severe confusion. The symptoms mentioned in the question do not align with this condition.
Choice D rationale
This is the correct answer. Postpartum fatigue is characterized by extreme tiredness that doesn’t get better with rest or sleep. This fatigue can make it difficult for the new mother to care for herself and her baby. The symptoms mentioned in the question - tearfulness, insomnia, lack of appetite, and a feeling of letdown - are all common symptoms of postpartum fatigue.
Correct Answer is C
Explanation
Choice C rationale
The apex of the heart is the most appropriate site to assess an infant’s heart rate. In infants, the apical pulse provides the most accurate assessment of heart rate. The apical pulse is located at the fifth intercostal space at the midclavicular line.
Choice A rationale
The carotid artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
Choice B rationale
The brachial artery can be used to assess an infant’s heart rate, but it is typically used for blood pressure measurements rather than heart rate assessments.
Choice D rationale
The radial artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
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