A neonate receiving an exchange transfusion develops respiratory distress, tachycardia, and a cutaneous rash. What nursing intervention should be implemented first?

• A. Stop the transfusion.
• B. Inform the healthcare provider.
• C. Administer calcium gluconate.
• D. Monitor vital signs electronically.

Answer: (A)

Recognizing an acute transfusion reaction and acting immediately to stop the transfusion is crucial. In a neonate during an exchange transfusion, the combination of respiratory distress, rapid heart rate, and a skin rash strongly suggests a transfusion reaction. The first priority is to stop the transfusion right away to halt further exposure to the donor blood and prevent progression of the reaction. After stopping, keep the IV line open with normal saline to maintain circulation and facilitate any needed medications, while you assess the airway and breathing and provide oxygen if indicated. Notify the healthcare provider and the blood bank promptly, and initiate the institution’s transfusion-reaction protocol, which typically includes obtaining samples for investigation and documenting reaction details. This initial action protects the patient from further harm and sets the stage for appropriate treatment and testing.

Informing the provider and initiating monitoring are essential, but they come after the immediate need to stop the transfusion. Administering calcium gluconate would only be appropriate for specific issues like citrate toxicity or hypocalcemia in other contexts, not as the first response to a suspected transfusion reaction. Continuous monitoring of vital signs is important, but stopping the transfusion takes precedence to prevent additional injury.