A nurse reports an incident of suspected child abuse. One of the child's parents becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

A. Obtaining a throat culture is contraindicated in suspected epiglottitis because it can cause laryngospasm and complete airway obstruction.
B. Placing the child in an upright position (such as the tripod position) helps to maximize airway patency and ease respiratory distress. This is a safe and supportive measure while preparing for definitive care.
C. While a lateral neck x-ray may be helpful in diagnosis, transporting the child can worsen distress, and airway stabilization takes priority before any diagnostic procedures.
D. Never attempt to visualize the epiglottis with a tongue depressor in suspected cases—this can trigger airway obstruction and is only done in a controlled setting like the OR with emergency airway support available.

A. Preparing the family for imminent death is premature and inappropriate as the first action. Hyper-cyanotic spells (Tet spells) are medical emergencies but often reversible with prompt intervention.
B. CPR is not the first response unless the child is unresponsive and pulseless. Tet spells are managed with specific interventions to reduce hypoxia.
C. Assessing for neurological defects may be important later, but during an acute Tet spell, the priority is to restore oxygenation and stabilize the child.
D. The first action during a Tet spell is to administer oxygen to reduce pulmonary vasoconstriction and improve oxygenation. This is often followed by placing the child in a knee-chest position, giving morphine, and preparing for further medical support as needed. Oxygen is the most immediate, non-invasive intervention.