A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
Prepare for an exchange blood transfusion.
Initiate early feeding.
Suction excess mucus with a bulb syringe.
Begin phototherapy.
The Correct Answer is B
A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.
B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.
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Related Questions
Correct Answer is B
Explanation
A. Petechiae and bleeding around the IV access site are not typically associated with preeclampsia.
B. Disseminated intravascular coagulation (DIC) is a potential complication of abruptio placentae, characterized by widespread activation of the clotting cascade followed by consumption of clotting factors, leading to bleeding and microvascular thrombosis.
C. Puerperal infection is a risk following childbirth but is not specifically associated with petechiae and bleeding around the IV access site.
D. Anaphylactoid syndrome of pregnancy is a rare complication characterized by sudden hypotension, bronchospasm, and vascular collapse, which is not typically associated with petechiae and bleeding around the IV access site.
Correct Answer is D
Explanation
A. Applying an ice pack may provide temporary relief from pain and swelling, but in this case, since the pain is unrelieved, a warm sitz bath would be more appropriate to promote relaxation and healing of the perineal area.
B. Applying a hot pack to the perineum may increase inflammation and discomfort rather than providing relief.
C. Providing a squeeze bottle of antiseptic solution may help with perineal hygiene but will not directly address the unrelieved pain from the episiotomy.
D. Offering a warm sitz bath can help soothe the perineal area, promote healing, and provide relief from episiotomy pain by increasing blood flow to the area and relaxing the muscles.
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