Pediatrics Question #7

Question

Which action by the nurse is most appropriate when a nurse hears a loud murmur on a newborn client with suspected trisomy 21 who has an echocardiogram scheduled later that day?

Vital signs:
Blood pressure: 90/60 mm Hg
Heart rate: 148/min
Respirations: 44/min
O 2 Sat: 97% on room air

Answers

  1. Quickly assist the infant to a knee-chest position.
    • Rationale:
  2. Call for stat arterial blood gases.
    • Rationale:
  3. Chart the findings and continue to monitor.
    • Rationale:
  4. Contact the health care provider stat.
    • Rationale:

Overview

Explanation

The correct answer is C. Hypercyanotic spells can be precipitated by activity. Being able to identify and intervene early by recording and monitoring the circumstances surrounding the spells may help to decrease the incidence. The knee-chest position can help with the immediate problem but will not reduce the number of hypercyanotic spells. Arterial blood gases will be drawn and monitored but this will not reduce the number of hypercyanotic spells. The health care provider would not need to be contacted at this point.

Learning Outcomes

Test Taking Tip

Video Rationale