A child is rushed to the emergency room due to cyanosis precipitated by crying. The parents note that after playing their child gets tired easily. The child is diagnosed with Tetralogy of Fallot. The immediate nursing intervention for cyanosis is:

Place her in the knee-chest position.

Explanation

•With Tetralogy of Fallot, there is 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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