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    Ati RN pediatrics 302 proctored exam 2
    Select All That Apply

    A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant suddenly becomes cyanotic, and his oxygen saturation reading drops to 60% Choose the interventions the nurse should perform. (Select All that Apply.)

    Explanation & Rationale

    A. Morphine sulfate is used to calm the infant and reduce respiratory effort, which decreases right-to-left shunting of blood and helps improve oxygenation during a "Tet spell." B. Administering IV fluids increases preload, which can help reduce the severity of the right-to-left shunting by promoting more blood flow to the lungs. C. Calling a code blue is not typically the first step unless the infant becomes unresponsive or pulseless. Tet spells can often be managed effectively with prompt nursing interventions. D. Placing the infant in a knee-to-chest position increases systemic vascular resistance, which reduces right-to-left shunting and improves oxygenation. E. Bronchodilators are used for bronchospasm-related respiratory issues (e.g., asthma), not congenital heart defects like Tetralogy of Fallot. F. Administering 100% oxygen by face mask helps improve oxygen saturation, although it is not the primary treatment, it supports oxygenation during the episode.

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