A 42-year-old mother was diagnosed with placenta previa, and her baby was delivered by cesarean section at 32 weeks. At birth, the infant has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds
Which of the following interventions are needed?
1. Monitor the infant's cardiac and respiratory status.
2. Have isotonic saline ready for transfusion.
3. Draw several vials of blood for laboratory testing.
4. Start the infant on iron supplements.
5. Have O-negative packed red cells ready for a transfusion.
6. Start the infant on phototherapy.
Correct Answer: 1,4,5
Rationale 1: This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment.
Rationale 2: Isotonic saline transfusion is used to treat polycythemia, not anemia. This treatment would worsen the patient's condition.
Rationale 3: Blood draws should be kept to a minimum for patients suffering from anemia.
Rationale 4: Iron supplements should be given to help increase red blood cell production.
Rationale 5: Patients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and crossmatched packed red cells should be used.
Rationale 6: Phototherapy should only be started if the infant has jaundice.
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