An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to:
a. Assess for neurologic defects.
b. Place the child in the knee-chest position.
c. Begin cardiopulmonary resuscitation.
d. Prepare the family for imminent death.
ANS: B
The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell; cardiopulmonary resuscitation is not necessary, and death is unlikely.
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