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Angela, a 3-year-old, is rushed to the emergency room due to cyanosis precipitated by crying. Her mother notes that after playing she gets tired easily. She is diagnosed with tetralogy of Fallot. The immediate nursing intervention for cyanosis is:

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 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.

•Next action of the nurse is to administer oxygen and morphine sulfate to reduce oxygen demand and increase oxygen sypply.

•Mechanical ventilation is usually not necessary.

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