The perinatal nurse is called to assess an infant 4 hours post-birth. The nurse notes a blue tinge to the lips, gums, and tongue of this infant. The nurse prepares for which of the following interventions? (Select all that apply.)
A.
Cardiac catheterization
B.
Echocardiogram
C.
Oxygen therapy
D.
Ultrasound
E.
Vital sign monitoring
ANS: A, B, C, E
At 4 hours after birth, the infant is usually crying and turning pink, although the hands and feet may remain slightly blue due to acrocyanosis. Central cyanosis is a condition related to vasomotor insufficiency and poor peripheral perfusion. If the infant's color remains blue, respiratory support is initiated according to hospital protocol. Oxygen may be administered via bag or mask. An echocardiogram and/or cardiac catheterization may be recommended to assess for heart abnormalities. Careful follow-up monitoring of vital signs (respiratory rate and heart rate) is indicated.
You might also like to view...
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.
When transferring a patient from a bed to a wheelchair, the nurse should
a. raise the height of the bed b. position the wheelchair 2 feet from the side of the bed c. lock the wheelchair brakes and elevate the foot pedals d. pivot the patient so the patient is facing the wheelchair
Which of the following statements best describes why health care of the homeless is so expensive to the community?
a. Health conditions of the homeless require increased preventive services. b. Homeless clients typically make more clinic visits for multiple health problems. c. Homeless people spread contagious diseases to those they pass on the street. d. Most care to homeless people takes place in hospital emergency departments.
A patient's goal was to ambulate 3 times, feed herself, and have a pain level of 3 out of 10. At the end of the day, the patient ambulated 3 times, ate by herself, and had a pain level of the 2/10. Has the goal been:
A. Met B. Partially met C. Unmet D. Not sufficient info to determine.