QuestionJuly 20, 2025

The 18-month-old hospitalized with uncorrected cyanotic heart disease, experiences a hyper "cyanotic spell (blue Tet spell). Which actions should be taken by the nurse? SELECT ALL THAT APPLY. A. Place the child in a knee chest position B. Administer 2 liters of oxygen via nasal cannula C. Administer intramuscular morphine sulfate D. Use a calm and comforting approach E. Administer oral propranolol prescribed

The 18-month-old hospitalized with uncorrected cyanotic heart disease, experiences a hyper "cyanotic spell (blue Tet spell). Which actions should be taken by the nurse? SELECT ALL THAT APPLY. A. Place the child in a knee chest position B. Administer 2 liters of oxygen via nasal cannula C. Administer intramuscular morphine sulfate D. Use a calm and comforting approach E. Administer oral propranolol prescribed
The 18-month-old hospitalized with uncorrected cyanotic heart disease, experiences a hyper "cyanotic spell (blue Tet spell). Which actions should be taken by the nurse? SELECT ALL THAT APPLY. A. Place the child in a knee chest position B. Administer 2 liters of oxygen via nasal cannula C. Administer intramuscular morphine sulfate D. Use a calm and comforting approach E. Administer oral propranolol prescribed

Solution
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Answer

A. Place the child in a knee chest position ### B. Administer 2 liters of oxygen via nasal cannula ### C. Administer intramuscular morphine sulfate ### D. Use a calm and comforting approach Explanation 1. Identify immediate physical intervention Placing the child in a knee-chest position helps increase systemic vascular resistance, reducing right-to-left shunting and improving oxygenation. 2. Oxygen administration Administering oxygen can help improve oxygen saturation during a cyanotic spell. 3. Medication for calming effect Morphine sulfate can be administered to reduce respiratory drive and calm the child. 4. Behavioral approach Using a calm and comforting approach can help reduce stress and prevent worsening of the spell. 5. Medication if prescribed Oral propranolol may be used to manage symptoms if prescribed.

Explanation

1. Identify immediate physical intervention<br /> Placing the child in a knee-chest position helps increase systemic vascular resistance, reducing right-to-left shunting and improving oxygenation.<br />2. Oxygen administration<br /> Administering oxygen can help improve oxygen saturation during a cyanotic spell.<br />3. Medication for calming effect<br /> Morphine sulfate can be administered to reduce respiratory drive and calm the child.<br />4. Behavioral approach<br /> Using a calm and comforting approach can help reduce stress and prevent worsening of the spell.<br />5. Medication if prescribed<br /> Oral propranolol may be used to manage symptoms if prescribed.
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