The nurse is caring for a 41-weeks'-gestation infant born yesterday. The newborn's hematocrit is 75%. The best action by the nurse based on this finding is to:
1. Inform the parents that their baby has an abnormal lab value.
2. Call the physician and report the hematocrit level.
3. Notify the blood bank that a transfusion will be required.
4. Increase breastfeeding frequency, and supplement between feedings.
2
Rationale 1: This answer is too vague. Parents need to know specifics, but described in lay terms.
Rationale 2: Polycythemia is a hematocrit above 65% and has the potential for serious sequelae, including stroke and respiratory distress. This infant requires a partial exchange transfusion to treat the polycythemia.
Rationale 3: This infant is not anemic but polycythemic. A partial exchange transfusion using crystalloids is the treatment.
Rationale 4: Increasing fluid intake will not improve the polycythemia. A partial exchange transfusion using crystalloids is the treatment.
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