章节:The Child with Cardiovascular and Hematologic Health Problems

SC
正确指数:75% 正确的次数:3 错误的次数:1 5099---A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first?

Saunders Comprehensive Review for the NCLEX-RN® Examination, 7e (Saunders Comprehensive Review for Nclex-Rn)

1. Obtain a prescription for sedation for the child.
2. Assess for an irregular heart rate and rhythm.
3. Explain to the child that it will only hurt for a short time.
4. Place the child in a knee-to-chest position.

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正确答案:
4. Place the child in a knee-to-chest position.
解释 :
The child is experiencing tet or hypoxic episode. Therefore, the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.