An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions should the nurse implement?
A)Administer oxygen.
B)Place the child in knee-chest position.
C)Administer morphine and propranolol intravenously as ordered.
D)Draw blood for a serum hemoglobin.
E)Administer Benadryl as ordered.

Question

Quizplus · Accepted Answer

Administering oxygen helps increase the oxygen saturation in the blood. Placing the child in a knee-chest position increases systemic vascular resistance, which helps to decrease the right-to-left shunting, thereby improving oxygenation. Administering morphine and propranolol as ordered can help by reducing the child's distress and decreasing heart rate, respectively, which can help manage the hypercyanotic episode.

An Infant with Tetralogy of Fallot (TOF) Is Having a Hypercyanotic