An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply.
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 diphenhydramine (Benadryl) as ordered.

Question

Quizplus · Accepted Answer

During a hypercyanotic episode in a child with TOF, the priority nursing interventions are to increase oxygenation and decrease systemic vascular resistance. Administering oxygen and placing the child in a knee-chest position can increase oxygen supply and decrease venous return, respectively. Medications such as morphine and propranolol can decrease systemic vascular resistance and relieve the cyanotic episode. Drawing blood for serum hemoglobin or administering diphenhydramine are not appropriate interventions for a hypercyanotic episode in a child with TOF.

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