An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should

thenurse implement first?

A. Provide 100% oxygen by face

mask B. Administer morphine

sulfate

C. Start intravenous fluids

D. Place the infant in a knee chest position

Answer: D An infant with tetralogy of Fallot will become acutely cyanotic and hyperpneic

during a hypercyanotic spell (transient exertional tachypnea or “TET” spell), so the nurse should

immediately place the infant in a knee chest position(D). The healthcare provider should be

notified and (A, B and C) implemented as prescribed.

The nurse is evaluating the effects of thyroid therapy used to treat a 5 month old with

hypothyroidism.Which behavior indicates that the treatment has been effective?

A. Laughs readily, turns from back to

side B. Has strong Moro and tonic neck

reflexes

C. Keep fists clenched, opens hands when grasping an

object D. Can lift head, but not chest when lying on

abdomen

Answer: A Laughing, and turning from back to side are expected in a 5 month old (A) and would

indicate that the thyroid treatment is effective. The Moro reflex should disappear after 3 to 4 months

and tonic reflex by 3 to 4 months (B); the presence of these reflexes is abnormal for a 5 month old

infant. (C and D) indicate abnormal growth and development associated with …

The nurse finds a 6 months old infant unresponsive and calls for help. After opening the airway

and finding the infant is still not breathing, which action should the nurse take?

A. Feel the carotid pulse and check adequate

breathing. B. Palpate the femoral pulse

and check regularity

C. Give two breaths that make the chest rise

D. Delivery cycles of 30 chest compressions and 2 breaths.

Answer: C Giving two breaths and checking for chest movement (C) assists the nurse in knowing if

the airway is obstructed. (A or B) are not helpful in assessing an infant. Based on the

recommendations of the American Heart Association, if the infant is unresponsive, the brachial pulse

should be checked followed by cycles of 20 chest compressions and 2 breaths (D).