A 3-year-old girl is rushed to the emergency room due to cyanosis precipitated by crying. Her mother notes that she gets tired easily after playing. The girl is diagnosed with Tetralogy of Fallot. The immediate nursing intervention for her cyanosis is

place her in the knee-chest position

Explanation

• Tetralogy of Fallot involves a ventricular septal defect that causes a right-to-left shunt. This results in deoxygenated blood entering the systemic circulation.

• When a child squats or is put in the knee-chest position, the pressure in the left side of the heart increases, resulting in less deoxygenated blood being shunted to the left side of the heart. This is the first action because it is the easiest and safest intervention.

• The next action of the nurse is to administer oxygen and morphine sulfate to reduce oxygen demand and increase oxygen supply.

• Incorrect: Mechanical ventilation is usually not necessary.

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