Pediatric ATI Practice Exam

What is the appropriate nursing action if a child shows sudden cyanosis due to congenital heart defects?

1. Administer supplemental oxygen

2. Begin cardiopulmonary resuscitation

3. Position the child upright

4. Notify the physician immediately

The correct answer is: Administer supplemental oxygen

Administering supplemental oxygen is the most immediate and appropriate nursing action if a child exhibits sudden cyanosis, particularly in the context of congenital heart defects. This condition indicates that the child is not receiving adequate oxygenation, which can occur due to various reasons associated with heart defects. By providing supplemental oxygen, you can help improve the oxygen saturation levels and enhance tissue oxygenation, which is crucial during an acute respiratory event. Supplemental oxygen can provide immediate support while further assessments and interventions are being planned or executed. It helps to stabilize the child’s condition by increasing the oxygen available in the bloodstream, potentially alleviating the cyanosis, which is often a sign of hypoxia. In situations of sudden cyanosis, assessing the need for further interventions, such as notifying the physician or initiating advanced treatments, will follow after ensuring that the child is receiving adequate oxygen.