Pediatric ATI Practice Exam

What should a nurse do if an infant with Tetralogy of Fallot shows signs of a hypercyanotic spell?

1. Place the infant in a knee-chest position.

2. Administer a dose of meperidine IV.

3. Discontinue IV fluid administration.

4. Apply oxygen at 2 L/min via nasal cannula.

The correct answer is: Place the infant in a knee-chest position.

Placing the infant in a knee-chest position is the appropriate intervention for managing a hypercyanotic spell in an infant with Tetralogy of Fallot. This position helps increase systemic vascular resistance, which can improve blood flow to the lungs by reducing the right-to-left shunt that characterizes this condition. During a hypercyanotic spell, oxygenated blood is shunted away from the lungs, leading to increased cyanosis and distress. By flexing the hips and knees and bringing them closer to the chest, the leg position compresses the femoral arteries, thereby increasing systemic vascular resistance. This action encourages the flow of blood to the pulmonary artery and enhances oxygenation. Other options would not effectively address the immediate needs during a hypercyanotic spell. For instance, administering opiates like meperidine is not beneficial in this scenario and may even be harmful for an infant experiencing acute distress. Discontinuing IV fluids could lead to dehydration and decreased blood volume, which is counterproductive in a critical situation. While oxygen can be beneficial, providing it via a low-flow nasal cannula would not be the most effective initial response compared to the immediate effects of repositioning the infant. Therefore, the knee-chest position is the most critical and