Author Question: The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls ... (Read 37 times)

Bernana · **on:** Jul 22, 2018

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing.

The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The ini-tial nursing action is to: 1. Call a code.
2. Place the infant in a prone position.
3. Place the infant in a knee-chest position.
4. Contact the respiratory therapy department.

Question 2

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, I don't know why I don't get out of this rotten situation.

Which of the following would be the therapeutic response by the nurse? 1. This is not a good time to make that decision.
2. What would your spouse think about your decision?
3. What aspects of this situation are the most difficult for you?
4. You seem to have a good grip on this situation. You probably should get out.

abctaiwan · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3

Rationale: If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore Call a code, place the infant in a prone position, and contact the respiratory therapy department are incorrect.

Answer to Question 2

3

Rationale: The most helpful response is one that encourages the client to explore the problem and problem-solve. What would your spouse think about your decision? disregards the client's concern and focuses instead on the reaction of the alcoholic spouse. The nurse should neither agree (You seem to have a good grip on this situation. You probably should get out.) nor disa-gree (This is not a good time to make that decision.) with the client. Giving advice implies that the nurse knows what is best and can also foster dependency.