Nokea
A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action?
- A. Assess for neurologic defects.
- B. Prepare the family for imminent death.
- C. Begin cardiopulmonary resuscitation.
- D. Place the child in the kneechest position.
Correct Answer: D
Rationale: Placing the infant in the knee-chest position increases systemic vascular resistance, reducing the hypercyanotic spell. Oxygen and morphine may follow, but this is the first action. Neurologic defects, CPR, or preparing for death are inappropriate initial responses.
You may also like to solve these questions
What term is defined as the volume of blood ejected by the heart in 1 minute?
- A. Afterload
- B. Cardiac cycle
- C. Stroke volume
- D. Cardiac output
Correct Answer: D
Rationale: Cardiac output is the volume of blood ejected by the heart per minute, calculated as heart rate times stroke volume. Afterload is resistance to ventricular ejection, cardiac cycle is the sequence of atrial and ventricular contraction, and stroke volume is the blood ejected per contraction.
What blood flow pattern occurs in a ventricular septal defect?
- A. Mixed blood flow
- B. Increased pulmonary blood flow
- C. Decreased pulmonary blood flow
- D. Obstruction to blood flow from ventricles
Correct Answer: B
Rationale: A ventricular septal defect allows blood to shunt from the high-pressure left ventricle to the lower-pressure right ventricle, increasing pulmonary blood flow. It?s a one-way shunt, not mixed flow, doesn?t obstruct ventricular outflow, and isn?t associated with decreased flow.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk?
- A. Minimize seizures.
- B. Prevent dehydration.
- C. Promote cardiac output.
- D. Reduce energy expenditure.
Correct Answer: B
Rationale: Preventing dehydration reduces stroke risk in hypoxic children with polycythemia, as dehydration increases blood viscosity. Seizure control, cardiac output, and energy expenditure are important but don?t directly address stroke risk.
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time?
- A. Administer oxygen.
- B. Record data on the nurses notes.
- C. Report data to the practitioner.
- D. Place the child in the high Fowler position.
Correct Answer: C
Rationale: A sleeping pulse over 160 beats/min suggests tachycardia, an early sign of heart failure due to sympathetic stimulation, requiring practitioner evaluation. Oxygen or positioning may be needed later, but reporting is the priority. Recording alone delays intervention.
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond?
- A. Elevate the affected extremity.
- B. Notify the practitioner of the observation.
- C. Record data on the assessment flow record.
- D. Apply warm compresses to the insertion site.
Correct Answer: C
Rationale: A weaker pulse post-catheterization is expected initially and should be documented as a baseline for monitoring. The pulse should strengthen over hours. Elevation, warm compresses, or immediate notification are unnecessary unless neurovascular changes occur.