The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing

Question

The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The ini-tial nursing action is to: 1. Call a code.
2. Place the infant in a prone position.
3. Place the infant in a knee-chest position.
4. Contact the respiratory therapy department.

Answer 1

3

Rationale: If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore "Call a code," "place the infant in a prone position," and "contact the respiratory therapy department" are incorrect.