Which structural defects constitute tetralogy of Fallot?

The correct answer is choice C. Explain in simple terms how it works.

Choice A rationale:

Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.

Choice B rationale:

Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.

Choice C rationale:

Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.

Choice D rationale:

Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.

The correct answer is Choice D: Jaundice.

Choice A rationale:

Vomiting can occur in biliary atresia due to the blockage of bile flow, but it is not the earliest clinical manifestation. Jaundice tends to precede vomiting and is a more characteristic early sign of biliary atresia.

Choice B rationale:

Hepatomegaly (enlargement of the liver) is a common finding in biliary atresia, but it usually occurs after the onset of jaundice. Jaundice is an earlier and more specific manifestation of this condition.

Choice C rationale:

Absence of stooling is a sign that might occur in biliary atresia due to the obstructed bile flow, but it is not typically the earliest clinical manifestation. Jaundice is generally the first noticeable sign.

Choice D rationale:

Jaundice is the earliest clinical manifestation of biliary atresia. It is caused by the buildup of bilirubin in the blood due to impaired bile flow from the liver. The jaundice in biliary atresia is typically progressive and can be one of the key indicators for further evaluation and diagnosis.