A nurse is assessing a client who has anaphylactic shock due to a bee sting.

Which of the following findings should the nurse expect?

The newborn’s skin color is pink.This indicates that the phototherapy is effective in lowering the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.

A pink skin color also means that the newborn is not jaundiced, which is a sign of high bilirubin levels.

Choice B is wrong because clay-colored stools indicate a problem with the liver or bile ducts.Bile is needed to give stools their normal brown color, and if bile is absent or blocked, the stools may become pale or clay-colored.This could be a sign of a serious condition such as biliary atresia, which is a congenital defect that causes bile ducts to be absent or malformed.

Choice C is wrong because a bilirubin level of 12 mg/dL is still high for a newborn and may require further treatment.The American Academy of Pediatrics recommends phototherapy for newborns with bilirubin levels above 15 mg/dL at 25 to 48 hours of age, 18 mg/dL at 49 to 72 hours of age, and 20 mg/dL at more than 72 hours of age.However, these thresholds may vary depending on the gestational age, risk factors, and clinical condition of the newborn.

Choice D is wrong because dark yellow urine may indicate dehydration or concentrated urine, which can increase the risk of bilirubin toxicity.Newborns receiving phototherapy should be well hydrated and have frequent wet diapers to help eliminate bilirubin from the body.Normal urine color for a newborn is pale yellow or clear.

Institute contact precautions.This is because the infant may havenecrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.

NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death.NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.

Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool.Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.

Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.

The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals.Decreasing the feeding may also compromise the infant’s growth and development.

Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.

Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition.Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.