Question

The nurse is caring for an infant client with tetralogy of Fallot who is experiencing a hypercyanotic spell. Place the actions the nurse should take in order of priority. All options must be used.

Select the correct sequence number for each item.

		1	2	3	4	5
1.	Administer 100% oxygen.	1	2	3	4	5
2.	Place the infant in a knee-chest position.	1	2	3	4	5
3.	Administer morphine sulfate as prescribed.	1	2	3	4	5
4.	Document the occurrence, actions taken, and the infant's response.	1	2	3	4	5
5.	Administer fluids intravenously.	1	2	3	4

Answer 1

Hypercytonic episodes often occur among infants with TET, and they occurs among infants whose heart defect includes they obstruction of pulmonary blood flow and Communication between the ventricles.if a hypercytonic episode occurs the infant a placed in a knee to chest position.the registered nurse is notified who will then contact the physician.there is no reason to call a code blue unless respiration ceases.100% O2, IV fluids, and morphine are all prescribed.

* place the infant in a knee -chest position - 1234

* administer 100% Oxygen -12345

* administer fluids intravenously - 12345

* administer morphine sulfate as prescribed-12345

* doccument the occurrence ,actions taken ,and the infants response - 12345