An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions should the nurse implement? Standard Text: 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 Benadryl as ordered.

Question

Quizplus · Accepted Answer

During a hypercyanotic episode, the infant may become cyanotic, agitated, and have a decreased level of consciousness. The knee-chest position can increase systemic vascular resistance and decrease right-to-left shunting, helping to alleviate cyanosis. Administering oxygen can help to increase oxygenation and relieve hypoxemia. Administering morphine can help to reduce systemic vascular resistance and anxiety, while propranolol can help to reduce heart rate and contractility. Drawing blood for a serum hemoglobin or administering Benadryl are not typically indicated in the management of a hypercyanotic episode in an infant with TOF.

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