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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A weight loss of 10% or more in infants within a short period is indicative of severe dehydration. The significant weight loss from 5 kg to 4.3 kg confirms this diagnosis.
B. The risk for fluid volume deficit would be noted if there were signs of potential dehydration, but in this case, the infant has already lost a significant amount of weight, confirming severe dehydration.
C. Failure to thrive is a diagnosis related to insufficient weight gain over time, rather than acute weight loss due to dehydration.
D. Malabsorption syndrome could contribute to chronic weight loss, but the acute loss in this case is more likely due to dehydration from diarrhea.
Correct Answer is A
Explanation
A. This is a common manifestation of hydrocephalus in newborns. The increased cerebrospinal fluid (CSF) in the ventricles causes the skull to expand, which can lead to prominent and dilated scalp veins due to increased intracranial pressure.
B. Over-riding suture lines are more commonly associated with conditions like craniosynostosis or during the early stages of labor when the skull bones overlap. In hydrocephalus, the sutures are more likely to be separated rather than overridden due to the expansion of the skull.
C. This is not a typical manifestation of hydrocephalus. Instead, you would expect a more pronounced or bulging forehead due to increased intracranial pressure.
D. Hypertension is not typically a manifestation of hydrocephalus in newborns. Instead, the condition is more associated with signs of increased intracranial pressure and changes in head size.
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