The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
a. Notify practitioner.
b. Stop the transfusion.
c. Administer calcium gluconate.
d. Monitor vital signs electronically.
ANS: B
When signs of cardiac or respiratory problems occur, the procedure is stopped, and the newborn's cardiorespiratory status is allowed to stabilize. The practitioner is usually performing the exchange transfusion with the nurse's assistance. The procedure must be stopped so the newborn can stabilize. Respiratory distress and tachycardia are signs of cardiorespiratory problems, not hypocalcemia. Calcium gluconate is not indicated. The vital signs should be monitored electronically throughout the entire procedure.
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