Nokea
Medical History
Nurses Notes
Infant has been feeding poorly and has had difficulty gaining weight. Admitted for feeding support and management.
Infant has Tetralogy of Fallot.
A nurse is assisting in the care of an infant who has congenital heart disease.
- A. Place the infant in a knee-chest position.
- B. Administer morphine via IV bolus.
- C. Provide 100% oxygen by face mask.
- D. Request a prescription for a diuretic.
- E. Perform nasopharyngeal suctioning for a maximum of 5 seconds.
- F. Prepare to assist with the insertion of a chest tube.
Correct Answer: A,B,C
Rationale: The knee-chest position morphine and oxygen are indicated for managing tet spells in Tetralogy of Fallot to improve oxygenation and reduce symptoms.
You may also like to solve these questions
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Restrain the child's arms.
- B. Insert a padded tongue blade into the child's mouth.
- C. Place the child in a side-lying position.
- D. Elevate the child's legs on a pillow.
Correct Answer: C
Rationale: This helps maintain an open airway and allows for drainage of saliva or vomit reducing the risk of aspiration.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
A nurse is reinforcing teaching about immunizations with the parents of a newborn. Which of the following statements should the nurse make?
- A. Your newborn will receive the first DTaP vaccine during the initial well-baby visit.
- B. Your newborn should receive an immunization for MMR at 6 months.
- C. Your newborn is scheduled to have a hepatitis B vaccine prior to discharge.
- D. Your newborn should receive the PCV vaccine two times prior to his first birthday.
Correct Answer: C
Rationale: Hepatitis B vaccine is recommended to be given within 24 hours of birth as the first dose of a series.
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.