Question

The nurse is caring for a 2-week-old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider?

1.Hemoglobin level of 24.9 g/dL (249 g/L)(38%)
2.Murmur noted on heart auscultation(10%)
3.Newborn becomes fatigued during feeding(31%)
4.Newborn has gained 0.6 lb (0.3 kg) since birth(19%)

Answer 1

The priority assessment finding to report for a 2-week-old client with Tetralogy of Fallot is a hemoglobin level of 24.9 g/dL (249 g/L)(38%), which is critically high and could indicate serious complications.

Step-by-step explanation:

The nurse caring for a 2-week-old client with Tetralogy of Fallot must prioritize assessment findings that could indicate significant health risks and require immediate medical intervention. Among the provided options, the highest priority to report to the health care provider is a hemoglobin level of 24.9 g/dL (249 g/L)(38%). This is critically high compared to the normal range for an infant, which can indicate polycythemia and cause serious complications, potentially as a response to chronic low oxygen levels due to the cardiac condition. The heart murmur is expected with Tetralogy of Fallot due to the structural abnormalities it entails. While fatigue during feeding can be a concern, it is not as immediately life-threatening as the abnormal hemoglobin level. Weight gain since birth is generally a positive sign unless there is concern about fluid retention or other issues, but it does not convey an immediate risk as the high hemoglobin level does.