Author Question: An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a ... (Read 77 times)

neverstopbelieb · **on:** Jun 28, 2018

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.
a. Administer 100 oxygen by blow-by.
b. Place infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line.

59. First priority

60. Second priority

61. Third priority

62. Fourth priority

Question 2

A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what conditions occur (Select all that apply)?

a. Respiratory rate of 36 at rest
b. Appetite slowly increasing
c. Temperature above 37.7 C (100 F)
d. New, frequent coughing
e. Turning blue or bluer than normal

samiel-sayed · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

59. ANS: B
60. ANS: A
61. ANS: D
62. ANS: C

Answer to Question 2

ANS: C, D, E
The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7 C (100 F); new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly.