During a tetralogy of Fallot (tet) spell, what is the nurse's priority action?

In a tetralogy of Fallot spell, often referred to as a “tet spell,” children may experience acute episodes of cyanosis and respiratory distress due to decreased blood flow to the lungs. The primary concern during these spells is to stabilize the child and ensure they are calm, as increased agitation can exacerbate the situation by further increasing oxygen demand and potentially leading to more severe symptoms.

Calming the infant is crucial because it helps decrease stress and lowers the heart rate, which can alleviate the severity of the symptoms. Anxiety can worsen the hypoxia associated with the spell, so promoting a calming environment is a priority. Techniques include positioning the child in a squatting position, which can help improve blood flow to the lungs and reduce cyanosis.

In contrast, while administering oxygen is important and often performed during a tet spell, calming the child takes precedence to address the immediate need for stability in their condition. Other interventions, such as notifying the healthcare provider and administering medications, are also important but would typically occur after ensuring the child is calm and stabilized.