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A nurse is caring for an infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take?

A. begin CPRR
B. prepare to intubate
C. administer adenosine
D. place infant in knee-chest position

1 Answer

3 votes

Final answer:

When caring for an infant with tetralogy of Fallot who experiences a hypercyanotic spell, the nurse should place the infant in a knee-chest position.

Step-by-step explanation:

The nurse should place the infant in a knee-chest position during a hypercyanotic spell. This position helps to increase vascular resistance and reduce the right-to-left shunt, thereby improving oxygenation. Hypercyanotic spells, also known as “blue spells,” occur when there is a sudden increase in the right-to-left shunting through the heart, leading to a decrease in the amount of oxygenated blood reaching the body. The knee-chest position brings the knees to the chest, which can help to alleviate this issue. This is a critical nursing intervention specific to the management of a hypercyanotic spell in infants with tetralogy of Fallot.

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