An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which of the following nursing interventions should the nurse implement? Select all that apply
1. Place the child in knee–chest position.
2. Draw blood for a serum hemoglobin.
3. Administer oxygen.
4. Administer morphine and propranolol intravenously as ordered.
5. Administer Benadryl as ordered.
1, 3, 4
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).
2. The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed.
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).
4. 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).
5. Benadryl is not appropriate for this child.
Implementation
Safe, Effective Care Environment
Application
Learning Outcome 26.4 Develop a nursing care plan for the child with a congenital heart defect cared for at home prior to corrective surgery.
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