The nurse is caring for a newborn receiving an exchange ...

[kwoodring]

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.

Question 2

When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
 
  a. At birth
  b. During first 24 hours after birth
  c. 24 to 48 hours after birth
  d. 48 to 72 hours after birth

[k.lashomb]

Answer to Question 1

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.

Answer to Question 2

ANS: B
In hemolytic disease of the newborn, jaundice is usually evident within the first 24 hours of life. Newborns with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present; 24 to 72 hours is too late for hemolytic disease of the newborn. Jaundice at these ages is most likely due to physiologic or early-onset breastfeeding jaundice.

[kwoodring]

Thank you

[k.lashomb]

Happy to help you