An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply
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 diphenhydramine (Benadryl) as ordered.
1, 2, 3
Explanation:
1. When an infant with 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).
2. When an infant with 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).
3. When an infant with 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).
4. The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed.
5. Benadryl is not appropriate for this child.
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