HESI RN Med Surg
HESI RN Med Surg ( 40 Questions)
During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?
Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.
Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.
Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.
Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.
Choice A reason: Obtaining a 12-lead electrocardiogram is not the first intervention that the nurse should implement. An electrocardiogram is a test that measures the electrical activity of the heart and can detect abnormalities in the heart rhythm or structure. However, it is not a priority for an infant who has already had surgical correction for TOF and is not showing signs of distress.
Choice B reason: Stimulating the infant to cry to produce cyanosis is not an intervention that the nurse should implement at all. Cyanosis is a bluish discoloration of the skin due to low oxygen levels in the blood. It is a common symptom of TOF and can be triggered by crying or other stressors. However, it is not a desirable outcome and can cause harm to the infant. The nurse should avoid provoking cyanosis and instead provide comfort and oxygen to the infant.
Choice C reason: Auscultating heart and lungs while the infant is held is the first intervention that the nurse should implement. This is a simple and noninvasive way to assess the infant's respiratory and cardiac status. The nurse can listen for any abnormal sounds, such as crackles, wheezes, or murmurs, that may indicate a problem. The nurse can also monitor the infant's heart rate and oxygen saturation. Holding the infant can provide comfort and security to the infant and the mother.
Choice D reason: Evaluating the infant for failure to thrive (FTT) is not the first intervention that the nurse should implement. FTT is a condition where an infant does not grow or gain weight as expected. It can be caused by various factors, such as inadequate nutrition, chronic illness, or psychosocial issues. However, the infant in this scenario is not showing signs of FTT, as his growth is in the expected range. The nurse should focus on the infant's current symptoms and needs.