A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should the nurse do first when the baby is crying and becomes severely cyanotic?
a. Place the infant in a knee-chest position.
b. Administer oxygen.
c. Administer morphine sulfate.
d. Calm the infant.
D
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A Placing the infant in a knee-chest position will decrease venous return so that
smaller amounts of highly saturated blood reach the heart. This should be done
after calming the infant.
B Administering oxygen is indicated after placing the infant in a knee-chest
position.
C Administering morphine sulfate calms the infant. It may be indicated some time
after the infant has been calmed.
D Calming the crying infant is the first response. An infant with unrepaired
tetralogy of Fallot who is crying and agitated may eventually lose consciousness.
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