Case study: Infant with hypercyanotic spell. A 6-month-old with tetralogy of Fallot becomes suddenly cyanotic and very irritable while crying during a diaper change. Which finding in this case is the highest priority for the nurse to address first?

Question

Accepted Answer

A. hypercyanotic spell causing decreased oxygenation — In this case, the highest-priority finding is hypercyanotic spell causing decreased oxygenation because it most directly threatens safety or signals clinical deterioration.

Answer

B. mild spit-up after a bottle

Answer

C. sleepiness after vaccines

Answer

D. sweaty scalp during feeding