Question

A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?

Answer 1

Correct Answers:

Left ventricular hypertrophy

Rationale :

🫀 Tetralogy of Fallot includes four defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy.

🫀 Left ventricular hypertrophy is not a component of this condition and suggests another pathology.

🫀 The presence of the VSD and pulmonary stenosis leads to right-sided pressure overload, not left.

🫀 This question requires recognition of the classic TOF tetrad.

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Answer 2

Correct Answers:

Upright

Rationale :

🌬️ Upright positioning improves lung expansion, allowing gravity to aid diaphragmatic movement and reduce work of breathing.

🌬️ Supine and prone positions restrict thoracic expansion, particularly in respiratory distress.

🌬️ Side-lying is more neutral but less effective than upright for maximizing ventilation.

🌬️ Children in respiratory failure need optimized positioning before other interventions.

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Answer 3

Correct Answers:

Maintain an updated hemophilus influence type b immunisation

Rationale :

💉 Children with sickle cell anemia are functionally immunocompromised due to splenic dysfunction, increasing the risk of infections, especially from encapsulated organisms like H. influenzae.

💉 Maintaining up-to-date vaccinations is critical for infection prevention.

💉 Limiting physical activity is not recommended unless during a crisis.

💉 Postural drainage has no role in this condition.

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Answer 4

Correct Answers:

Give the child a stuffed animal.

Rationale :

🧸 Offering a transitional object like a toy provides comfort and security during separation anxiety, which is common in toddlers.

🧸 Telling time (e.g., 2 hours) is inappropriate at this age—they don’t understand time concepts.

🧸 Leaving the child alone or calling the parent immediately isn't developmentally supportive.

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Answer 5

Correct Answers:

On the nonoperative side

Rationale :

🛏️ After ventriculoperitoneal shunt placement, the child should be positioned on the nonoperative side to reduce pressure on the surgical site and prevent CSF leakage.

🛏️ Prone and supine increase risk of complications.

🛏️ Elevating the head immediately post-op may impair shunt function.

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Answer 6

Correct Answers:

Maintain integrity of the sac.

Rationale :

🩺 In infants with myelomeningocele, the exposed sac must be protected to prevent infection and rupture.

🩺 This is the top priority before surgery.

🩺 Maternal bonding and stimulation are important but come after ensuring physical integrity.

🩺 Parental education can follow once stability is achieved.

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Answer 7

Correct Answers:

"At this age you should expect your child to be upset when you leave.'

Rationale :

👶 Crying when parents leave is a normal sign of separation anxiety, especially at 8 months when object permanence develops.

👶 This response reassures parents and reflects normal child development.

👶 The other statements dismiss or misinterpret the behavior.

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Answer 8

Correct Answers:

Increased restlessness

Rationale :

😰 Restlessness is an early sign of hypoxia and impending airway obstruction in laryngotracheobronchitis (croup).

😰 Stridor may decrease right before complete obstruction—so it’s not reassuring.

😰 Temperature and HR changes are nonspecific or late signs.

😰 Continuous monitoring is essential.

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Answer 9

Correct Answers:

Place the infant in prone position.

Rationale :

🛡️ For infants with spina bifida, especially myelomeningocele, prone positioning avoids pressure on the lesion and protects its integrity.

🛡️ Dry cloths are inadequate—lesions should be covered with sterile, moist dressings.

🛡️ NG tube feeding is not standard unless needed.

🛡️ Diapering over the defect risks contamination and infection.

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Answer 10

Correct Answers:

A private room with contact/droplet precautions

Rationale :

🦠 RSV is highly contagious and transmitted via droplet and contact, requiring isolation.

🦠 A private room minimizes spread; cohorting only works with another RSV case.

🦠 Reverse isolation is unnecessary unless immunocompromised.

🦠 Croup and pneumonia may involve different organisms, making shared rooms unsafe.

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QLexNursing

1 :
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?

2 :
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?

3 :
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?

4 :
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?

5 :
A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions?

6 :
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?

7 :
A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?

8 :
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

9 :
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

10 :
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?

QLexNursing

1 : A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?

2 : A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?

3 : A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?

4 : A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?

5 : A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions?

6 : A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?

7 : A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?

8 : A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

9 : A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

10 : A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?

1 :
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?

2 :
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?

3 :
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?

4 :
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?

5 :
A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions?

6 :
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?

7 :
A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?

8 :
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

9 :
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?

10 :
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?