Author Question: An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and ... (Read 63 times)

oliviahorn72 · **on:** Jun 28, 2018

An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday.

What information by the nurse is most accurate?
A.
Blood incompatibilities can cause this problem, so we will test the mother's blood.
B.
Symptoms may not appear until fetal circulation routes begin to close after birth.
C.
The extra blood from the umbilical cord may have kept the baby stable for a while.
D.
Your baby may have gotten an infection during birth that now is causing problems.

Question 2

A nurse takes a newborn's initial set of vital signs and records the following: Temperature: 97.9 F (36.6C), pulse: 198 beats/minute, respirations: 78 breaths/minute, blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant?

A.
Hypotensive: needs IV fluid administration
B.
Hypothermic: needs to be put in an incubator
C.
Tachycardic: take pulse again when baby is not crying
D.
Tachypneic: suction if needed, administer oxygen per protocol

bfulkerson77 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
This baby has clinical manifestations of tetralogy of Fallot. While the ductus arteriosus remains patent, the infant remains stable. However, when the ductus begins closing after the first 24 hours of life, the infant's cardiovascular system becomes unstable and manifestations appear. The other statements are inaccurate.

Answer to Question 2

ANS: D
A normal respiratory rate for an infant is 30-60 breaths/minute. This respiratory rate is too rapid, and the nurse needs to suction the infant if needed and provide oxygen per protocol. The blood pressure and temperature are normal. The heart rate is too fast, even for a crying baby.