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
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.

A. Expect some breast dimpling or discharge with age. B. Using the palm of the hand, feel for lumps using a circular motion. C. Breasts can be examined in the shower with soapy hands. D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.

Correct Answer is C

Explanation

Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.

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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 caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?

Correct Answer is B

Explanation

A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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

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