The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
"If the baby turns blue, I will immediately put the baby upright in an infant seat."
"If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body."
"If the baby turns blue, I will put the baby in supine position with his head elevated."
"If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest."
The Correct Answer is D
This position, often referred to as the "knee-to-chest" position, is recommended during a cyanotic spell in infants with tetralogy of Fallot because it can help increase venous return to the heart and improve oxygenation. It's important for caregivers to understand this positioning as part of the management for hypercyanotic spells in children with this condition.
A. Placing the baby upright in an infant seat may help improve blood flow and oxygenation, but it's not the recommended position for managing cyanosis in a baby with tetralogy of Fallot.
B. Placing the baby with the head lower than the rest of the body could potentially worsen cyanosis by increasing right-to-left shunting of blood and decreasing pulmonary blood flow.
C. Placing the baby in a supine position with the head elevated worsens pulmonary blood flow by increasing systemic vascular resistance. This position can help worsen cyanosis by promoting better oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.
B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.
C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.
D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.
Correct Answer is C
Explanation
C. Salicylates, such as aspirin, should be avoided in children and adolescents with viral symptoms due to the association with Reye's syndrome. Instead, acetaminophen or other non-steroidal anti-inflammatory drugs (NSAIDs) without salicylates should be used for fever and pain relief.
A. Reye's syndrome typically presents with symptoms such as fever, vomiting, and lethargy. However, there isn't a specific test for Reye's syndrome itself. Diagnosis is often based on clinical symptoms, history of aspirin use, and laboratory findings.
B. Reye's syndrome is associated with the use of aspirin (salicylates) in children and adolescents with viral infections, particularly influenza and chickenpox. Acetaminophen (Tylenol) is recommended instead of aspirin for fever and pain relief in children with viral illnesses.
D. There isn't a specific vaccine for Reye's syndrome. Reye's syndrome is not caused by an infectious agent that can be prevented through vaccination.
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