Question

the nurse is caring for an infant with tetralogy of fallot when the infant begins crying inconsolably and becomes cyanotic. which of the following actions should the nurse take first? 1. administer intravenous morphine. 2. notify the health care provider about the episode. 3. comfort infant and place in the knees - to - chest position. 4. start an intravenous 0.9% sodium chloride (normal saline) bolus.

Explanation:

Tetralogy of Fallot causes cyanotic spells (blue spells) when crying increases oxygen demand. The knees-to-chest position is the immediate first intervention: it increases systemic vascular resistance, reducing right-to-left shunting of deoxygenated blood and improving oxygenation. Other interventions like morphine, notifying the provider, or IV fluids are secondary to this initial positioning and comfort.

Answer:

1. Comfort infant and place in the knees-to-chest position.