Pediatric ATI Practice Exam

What should a nurse expect when monitoring an infant with transportation of great vessels?

1. Normal oxygen saturation levels

2. Cyanosis that worsens upon crying

3. Low blood pressure

4. Increased respiratory rate

The correct answer is: Cyanosis that worsens upon crying

In cases of transposition of the great vessels, the nurse should expect cyanosis that worsens upon crying. This condition involves a defect where the aorta and pulmonary artery are swapped, resulting in the separation of oxygenated and deoxygenated blood. As a result, the infant may appear cyanotic from birth because the blood that is delivered to the body is not properly oxygenated. When the infant cries, there is often an increase in respiratory effort and oxygen demand, leading to a further decrease in oxygen saturation levels and exacerbation of the cyanosis. This reduced capacity for oxygen exchange is critical to monitor because it indicates the severity of the condition and helps guide interventions. Other potential answers such as normal oxygen saturation levels, low blood pressure, and increased respiratory rate could be present in certain circumstances, but the hallmark of transposition of the great vessels is cyanosis, particularly under stress such as crying, which can provide essential insights into the infant's oxygenation status and the effectiveness of their circulation.