An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?

Correct Answer: C

Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.

Correct Answer: D

Rationale: In the context of pediatric nursing, particularly in caring for a teenager with sickle cell anemia, understanding dietary considerations is crucial. Choosing the correct drink on a hot day reflects this understanding. The correct choice, lemonade (Option D), is the best option because it is often recommended for individuals with sickle cell anemia due to its high vitamin C content, which can help reduce oxidative stress and inflammation associated with the disease. Milkshake (Option A) is high in dairy fat and sugar, which can contribute to weight gain and potentially exacerbate symptoms of sickle cell anemia. Iced tea (Option B) and diet cola (Option C) may contain caffeine, which can lead to dehydration, a concern for individuals with sickle cell anemia who are already at risk for dehydration due to increased water loss from sickling of red blood cells. Educationally, this question highlights the importance of nutrition in managing sickle cell anemia and reinforces the need for healthcare providers to educate patients and their families about making appropriate dietary choices to support their health. It also underscores the significance of understanding the specific needs and considerations for individuals with chronic conditions like sickle cell anemia.

Correct Answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required.

Correct Answer: A

Rationale: The correct answer is A) Describe the side-lying, knees-to-chest position that must be assumed during the procedure. This is the most appropriate response because it provides essential information to prepare the child for the lumbar puncture procedure. By describing the position the child needs to be in, the nurse ensures the child understands what to expect and can cooperate better during the procedure. Option B) Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure is incorrect because it does not address the child's immediate concerns about the procedure itself. This information is important but not as crucial as preparing the child for the procedure itself. Option C) Reassuring the child that there will be no restrictions on activity after the procedure is completed is incorrect as it does not address the child's anxiety or provide information about the procedure. Option D) Telling the child to expect loud clicking noises during the procedure that may be slightly annoying is incorrect as it may increase the child's anxiety without providing useful information to help the child cope during the procedure. Educationally, when preparing a child for a medical procedure, it is crucial to provide clear, age-appropriate information to reduce anxiety and facilitate cooperation. Describing the procedure in a simple and understandable way helps build trust between the child and healthcare provider, leading to a more positive experience for the child.

Correct Answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. It is important to verify the child's immunization status before considering other interventions.