Difficulty: Medium
Average Score: 72%
Simulated
Passage / Scenario
A nurse is caring for a 6-month-old Infant with a diagnosis of Tetralogy of Fallot (TOF) who is experiencing a hypercyanotic spell. The Infant is lethargic and has a weak cry.What is the priority nursing action for this Infant?
Correct answer
D
Rationale
The correct answer is D: Place the infant in a knee to chest position. This position helps relieve gas and abdominal distension in infants, which can cause discomfort and crying. By positioning the infant in knee to chest, it helps to expel trapped gas and alleviate the discomfort. Administering morphine sulfate (choice A) is not recommended as the first action without addressing the cause of distress. Providing supplemental oxygen (choice B) is not necessary if the issue is gas-related. Offering a pacifier (choice C) may temporarily distract the infant but does not address the underlying issue.