QUESTION: "A viable male neonate delivered by cesarean section is scheduled for an immediate exchange transfusion. In planning the neonate's care during the exchange transfusion, the nurse would include which of the following measures?"
CHOICES
( X ) a.) Administer calcium gluconate intramuscularly before the procedure.
( O ) b.) Monitor the neonate's status before and during the procedure.
( X ) c.) Administer heparin before the procedure.
( X ) d.) Keep the phototherapy lights on during the procedure.
RATIONALE: Nursing responsibilities include assembling the equipment, preparing the neonate and parents, assisting the physician during the procedure, monitoring the neonate's status before and during the procedure, and maintaining careful records. The neonate should be in a warm environment, preferably under a radiant warmer, and should be NPO for at least 4 hours before the procedure to prevent possible aspiration. The parents should be kept informed of the neonate's condition. Calcium gluconate is not given before the procedure but it may be administered intravenously after each 100 mL of blood infusion, if indicated to counteract the possible hypocalcemia that may occur from the transfusion. Blood stored for transfusion contains acid-citric-dextrose to prevent clotting. This can lower calcium levels. Heparin administration is not performed before the procedure. Phototherapy lights are not necessary during the procedure. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
