What is the priority nursing intervention for a newborn infant diagnosed with transposition of the great vessels?
Preparing the infant for immediate surgery
Initiating feeding through a nasogastric tube
Administering oxygen via nasal cannula
Administer prostaglandin E1 (PGE1) to maintain patency of the ductus arteriosus
The Correct Answer is D
A. Preparing for immediate surgery is necessary, but the priority intervention is to ensure adequate oxygenation and blood flow through the ductus arteriosus before surgery can be performed.
B. Initiating feeding through a nasogastric tube is not a priority for an infant with this condition, as their immediate need is to address the circulatory issue rather than feeding.
C. Administering oxygen via nasal cannula may provide some relief but is not sufficient as a standalone intervention for transposition of the great vessels, which requires maintaining ductal patency to allow mixing of oxygenated and deoxygenated blood.
D. Administering prostaglandin E1 (PGE1) is the priority intervention, as it helps maintain patency of the ductus arteriosus, allowing for temporary stabilization of the infant’s condition until surgical intervention can be performed.
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Correct Answer is D
Explanation
A. Weak pulses are more indicative of reduced cardiac output or other cardiac issues, rather than specifically a large patent ductus arteriosus (PDA).
B. Cyanosis with crying can occur in various conditions, but it is not a hallmark of a large PDA; it typically presents with other symptoms.
C. Chronic hypoxemia is more associated with severe heart defects or lung conditions, whereas a large PDA may present with other signs first.
D. A systolic murmur is a classic finding in large PDAs due to the left-to-right shunting of blood, making it the most expected manifestation in this scenario.
Correct Answer is A
Explanation
A. A child with varicella (chickenpox) should return to school only after all the blisters have crusted over, indicating that the infectious stage has passed and they are no longer contagious.
B. Receiving the varicella vaccine does not apply to children who already have the infection; vaccination is preventive, not a treatment for those already infected.
C. Completing one week of antiviral medication is not a sufficient criterion for returning to school, as the child may still be contagious until all lesions are crusted.
D. Returning to school as soon as the rash appears is not safe, as the child is highly contagious during the initial rash stage and until all lesions have crusted.