The nurse assessing an infant will be most concerned about which of the following findings?
a. peripheral cyanosis of the hands c. cyanosis of the lips or tongue
b. perioral cyanosis d. cyanosis of the feet
C
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A Incorrect. Peripheral cyanosis of the hands is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis.
B Incorrect. The nurse will not be most concerned about perioral cyanosis (cyanosis of the skin around the lips).
C Correct. The nurse will be most concerned about cyanosis of the lips or tongue. This finding may indicate a cardiovascular alteration. Cyanosis appears when hemoglobin, approximately 5g/dl of blood, circulates unbound to oxygen and the measured oxygen saturation drops below 85%.
D Incorrect. Cyanosis of the feet is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis.
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