An infant with tetralogy of Fallot is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate for the nurse to implement for this infant? Select all that apply.

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Quizplus · Accepted Answer

During a hypercyanotic episode, also known as a "tet" spell, the nurse should implement measures to increase systemic vascular resistance and decrease pulmonary vascular resistance. Placing the child in the knee-chest position can increase systemic vascular resistance by increasing venous return and decreasing the amount of blood returning to the lungs. Administering oxygen can also help to increase systemic oxygenation and decrease hypoxia. Administering medications such as morphine and propranolol can help to decrease pulmonary vascular resistance. Drawing blood for a serum hemoglobin or administering Benadryl are not appropriate interventions for a hypercyanotic episode.

An Infant with Tetralogy of Fallot Is Having a Hypercyanotic