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?

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Infants with tetralogy of Fallot (TOF), a cyanotic cardiac defect, experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poorly oxygenated blood. To compensate for prolonged tissue hypoxia, erythropoietin production increases to produce additional oxygen-carrying RBCs. Increased RBCs result in increased circulatory viscosity or polycythemia (ie, hemoglobin >22 g/dL [220 g/L] or hematocrit >65%). Polycythemia increases the risk for blood clotting (ie, thrombus formation), which can cause stroke. Therefore, a hemoglobin level of 24.9 g/dL (249 g/L) is a priority to report to the health care provider because close observation and additional interventions such as IV hydration and (possibly) partial exchange transfusion are required (Option A). (Option B) A loud, systolic ejection murmur is characteristic of TOF and not a priority to report because the diagnosis is established. (Options C and D) Infants with TOF may commonly experience frustration or fatigue due to increased oxygen demands during feedings. Therefore, poor weight gain is not unusual. Healthy infants gain about 1 ounce (30 g) per day or 0.5 lb (0.2 kg) per week for the first 3 months. The nurse should report these findings, but they are not more important than polycythemia, which requires immediate assessment and intervention. Educational objective: Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because increased circulatory viscosity increases the risk for thrombus formation and stroke.

The Nurse Is Caring for a 2-Week-Old Client Who Has