A 3-month-old infant has a hypercyanotic spell. What should be the nurse's first action?
a. Assess for neurologic defects.
b. Prepare the family for imminent death.
c. Begin cardiopulmonary resuscitation.
d. Place the child in the knee–chest position.
ANS: D
The first action is to place the infant in the knee–chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. Preparing the family for imminent death or beginning cardiopulmonary resuscitation should be unnecessary. The child is assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
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