The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:

Place him in knee-chest position

Have him lie prone, being sure he can breathe easily

Have him lie supine with the head turned to one side

Place him in semi-fowler's position in an infant seat

Answer and Explanation

The Correct Answer is A

A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.

B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.

C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.

D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.

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Correct Answer is C

Explanation

A. This site is used most often to obtain a pulse in infants during CPR or blood pressure measurement, but it does not provide the most accurate heart rate assessment.

B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.

C. The apical pulse (measured with a stethoscope at the 4th intercostal space, left midclavicular line) is the most accurate site for infants and children under 2 years old. It directly reflects the heart’s activity and is less affected by peripheral perfusion.

D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.

A. Contact B. Droplet C. Protective environment D. Airborne

Correct Answer is D

Explanation

A. Contact precautions are used for infections that spread through direct or indirect contact with contaminated surfaces or items, which is not the case for measles.

B. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but measles requires different precautions.

C. Protective environment precautions are used for immunocompromised patients to prevent infections but are not specific to measles.

D. Measles is spread through airborne droplets, so airborne precautions are required to prevent the spread of the virus through the air.

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The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:

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