An infant with an unrepaired tetralogy of Fallot defect is becoming
extremely cyanotic during a routine blood draw. Which
interventions should the nurse implement? Place in order from the
highest-priority intervention to the lowest-priority intervention.
Select all that apply:
a. Administer 100% oxygen by blow-by. #2
b. Place the infant in knee-chest position.#1
c. Remain calm.#4
d. Give morphine subcutaneously or by an existing
intravenous line.#3 ANS B,A,D,C
Hypercyanotic spells, also referred to as blue spells or tet spells
because they are often seen in infants with tetralogy of Fallot,
may occur in any child whose heart defect includes obstruction to
pulmonary blood flow and communication between the ventricles.
The infant becomes acutely cyanotic and hyperpneic because
sudden infundibular spasm decreases pulmonary blood flow and
increases right-to-left shunting. Because profound hypoxemia
causes cerebral hypoxia, hypercyanotic spells require prompt
assessment and treatment to prevent brain damage or possibly
death. The infant should first be placed in the knee-chest position
to reduce blood returning to the heart. Next 100% oxygen is
given to alleviate the hypoxemia. Morphine is next administered
,NURS 340 PEDS CH 23 Exam Questions and Answers
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to reduce infundibular spasms. Last, the nurse should remain
calm.
DIF: Cognitive Level: Apply REF: p. 741
A chest radiograph film's ordered for a child with suspected
cardiac problems. The child's parent asks the nurse, "What will
the radiograph show about the heart?" What knowledge about
the x-ray should the nurse include in the response to the
parents?
a. Bones of chest but not the heart.
b. Measurement of electrical potential generated from heart
muscle.-ekg
c. Permanent record of heart size & configuration.
d. Computerized image of heart vessels &
tissues. -echo ANS: C
A chest radiograph will provide information on the heart size and
pulmonary blood-flow patterns. It will provide a baseline for
future comparisons. The heart will be visible, as well as the
sternum and ribs. Electrocardiography (ECG) measures the
electrical potential generated from heart muscle.
Echocardiography will produce a computerized image of the
heart vessels and tissues by using sound waves.
DIF: Cognitive Level: Understand REF: p. 738
2. The nurse is assessing a child after a cardiac
catheterization. Which complication should the nurse be
assessing for?
a.Cardiac arrhythmia.
b.Hypostatic pneumonia.
c.Heart failure.
d.Rapidly increasing blood
pressure. ANS A
Because a catheter is introduced into the heart, a risk exists of
catheter-induced dysrhythmias occurring during the procedure.
These are usually transient. Hypostatic pneumonia, heart failure,
and rapidly increasing blood pressure are not risks usually
associated with cardiac catheterization.
DIF: Cognitive Level: Apply REF: p. 739
3.José is a 4-year-old child scheduled for a cardiac
catheterization. What should be included in preoperative
teaching?
a.Directed at his parents because he is too young to understand.
b.Detailed in regard to the actual procedures so he'll know what to
expect.
c.Done several days before the procedure so that he'll be
, NURS 340 PEDS CH 23 Exam Questions and Answers
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prepared.
d.Adapted to his level of development so that he
can understand. ANS: D
Preoperative teaching should always be directed at the child's
stage of development. The caregivers also benefit from the
same explanations. The parents may ask additional questions,
which should be answered, but the child needs to receive the
information based on developmental level. Preschoolers will
not understand in-depth descriptions and should be prepared
close to the time of the cardiac catheterization. DIF: Cognitive
Level: Apply REF: p. 739
4.Which explanation regarding cardiac catheterization is
appropriate for a preschool child?
a.Postural drainage will be performed every 4-6 hours after the
test.
b.It's necessary to be completely "asleep" during the test.
c.The test's short, usually taking less than 1 hour.
d.When the procedure is done, you'll have to keep your leg
straight for at least 4 hours. ANS: D
The child's leg will have to be maintained in a straight position
for approximately 4 hours. Younger children can be held in the
parent's lap with the leg maintained in the correct position.
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