What are the nursing priorities for a 2‑hour‑old term newborn weighing 2700 g with hypotension (arm blood pressure 65/44 mm Hg, leg blood pressure 50/32 mm Hg), head circumference 34 cm, chest circumference 31 cm, pink appearance, crying, a soft systolic murmur, and weak left pedal pulses?

Nursing Priorities for Newborn with Suspected Coarctation of Aorta

This 2-hour-old newborn requires immediate cardiology consultation and urgent echocardiography because the blood pressure differential (arm 65/44 vs leg 50/32 mmHg) with weak lower extremity pulses and systolic murmur strongly suggests critical coarctation of the aorta, a ductal-dependent lesion that can rapidly deteriorate as the ductus arteriosus closes. 1

Immediate Assessment Priorities

Confirm Four-Extremity Blood Pressures

• Measure blood pressure in the right arm (pre-ductal) using proper technique with cuff width 0.45-0.55 times arm circumference, ensuring the infant is in a quiet state for at least 15 minutes before measurement 2, 3
• Obtain bilateral leg pressures to confirm the gradient; normal neonates have ankle-brachial index (ABI) of 0.88 ± 0.11, but this infant shows reversed gradient (legs lower than arms) which is pathological 4
• A systolic gradient >20 mmHg between upper and lower extremities is diagnostic of coarctation 1

Assess Perfusion Status

• Evaluate capillary refill time (should be ≤2 seconds); prolonged CRT indicates shock 1, 5
• Compare pulse quality between right arm (pre-ductal) and femoral/pedal pulses; the described weak left pedal pulses with differential between upper and lower extremities confirms compromised lower body perfusion 1, 5
• Monitor for signs of shock: cool extremities, altered mental status, decreased urine output (<1 mL/kg/hr), tachycardia 1, 5

Critical Interventions

Maintain Ductal Patency

• Initiate prostaglandin E1 (PGE1) infusion immediately at 0.05-0.1 mcg/kg/min to maintain ductal patency and restore lower body perfusion in this ductal-dependent lesion 1
• Monitor for PGE1 side effects: apnea (most common), hypotension, fever 1
• Prepare for potential intubation as apnea occurs in up to 12% of neonates on PGE1 1

Hemodynamic Support

• Establish secure IV access (umbilical venous line preferred in first hours of life) 1
• Administer fluid boluses of 10 mL/kg isotonic crystalloid if signs of shock develop, observing for hepatomegaly and increased work of breathing 1
• Prepare inotropic support (dopamine <8 mcg/kg/min plus dobutamine up to 10 mcg/kg/min, or epinephrine 0.05-0.3 mcg/kg/min) if perfusion does not improve with fluids 1

Continuous Monitoring Requirements

Vital Signs

• Continuous pulse oximetry on right hand (pre-ductal) and either foot (post-ductal) to detect differential oxygen saturation; >5% difference suggests right-to-left ductal shunting 1
• Continuous electrocardiogram monitoring for arrhythmias 1
• Four-extremity blood pressure every 15-30 minutes initially, then hourly once stable 1, 5
• Temperature monitoring (axillary preferred to avoid skin trauma) 1

Laboratory Monitoring

• Arterial or venous blood gas to assess metabolic acidosis (indicates inadequate perfusion) 1, 5
• Serum glucose and ionized calcium every 2-4 hours; correct hypoglycemia with D10% infusion at maintenance rate 1, 5
• Lactate and anion gap to assess tissue perfusion 1
• Complete blood count and blood culture if sepsis cannot be excluded 5

Perfusion Assessment

• Urine output monitoring with goal >1 mL/kg/hr; oliguria indicates inadequate renal perfusion 1, 5
• Serial capillary refill assessments every 15 minutes during resuscitation 5
• Mental status evaluation (strong cry vs weak cry, alertness) 5

Therapeutic Endpoints

Target the following parameters 1, 5:

• Capillary refill ≤2 seconds
• Warm extremities with equal pulses in all four extremities
• Urine output >1 mL/kg/hr
• Normal mental status (strong cry, alert)
• ScvO2 >70%
• Reduction in upper-to-lower extremity blood pressure gradient
• Absence of metabolic acidosis

Critical Pitfalls to Avoid

• Never delay PGE1 infusion while awaiting echocardiography; clinical suspicion alone warrants treatment in ductal-dependent lesions 1
• Do not assume the infant is stable because of pink color and crying; neonates can maintain adequate pre-ductal (upper body) perfusion while lower body is critically ischemic 1
• Avoid excessive fluid administration (>60 mL/kg in first hour) without reassessing for hepatomegaly and pulmonary edema 1
• Do not use dopamine as sole agent if shock persists; its effect on pulmonary vascular resistance may be detrimental 1
• Monitor closely for apnea after PGE1 initiation; have intubation equipment immediately available 1