A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

Notify the registered nurse.
Prepare to administer morphine sulfate.
Prepare to administer intravenous fluids.
Prepare to administer 100% oxygen by face mask.

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs. the infant is placed in a knee-chest position immediately. The registered nurse is notified. who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask. morphine sulfate. and intravenous fluids. as prescribed.