The perinatal nurse is called to assess an infant 4 hours ...

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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

Question 2

The perinatal nurse carefully assesses an infant for evidence of maternal alcohol use. Characteristics the nurse assesses for include which of the following? (Select all that apply.)
 
  A.
  Coloboma
  B.
  Irritability
  C.
  Periauricular skin tags
  D.
  Smooth philtrum
  E.
  Thin upper lip

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Answer to Question 1

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.

Answer to Question 2

ANS: B, D, E
Characteristic findings of maternal alcohol use include short palpebral fissures; a flattened nasal bridge with a small, upturned nose, flat midface, and thin upper lip; and smooth philtrum. Alcohol-related birth defects also include poor growth, mental retardation (often associated with microcephaly, or small head), and small chin (micrognathia). These babies may be jittery and irritable and feed poorly.