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

Question

1. Administer oxygen.
2. Place the child in knee-chest position.
3. Administer morphine and propranolol intravenously as ordered.
4. Draw blood for a serum hemoglobin.
5. Administer Benadryl as ordered.

Answer 1

1,2,3
Rationale 1: When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
Rationale 2: When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
Rationale 3: When an infant with tetralogy of Fallot (TOF) has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
Rationale 4: The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed.
Rationale 5: Benadryl is not appropriate for this child.
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