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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Rationale for A: Drying the skin is crucial to prevent hypothermia, as newborns can quickly lose body heat. This action also stimulates the newborn and promotes circulation.
Rationale for B: Administering eye prophylaxis is important to prevent gonococcal ophthalmia, but it can be done after ensuring the newborn is warm and stable.
Rationale for C: Placing an identification bracelet is necessary for safety, but it is not as immediate a concern as ensuring the newborn's temperature is regulated.
Rationale for D: Administering vitamin K is important for preventing hemorrhagic disease in newborns, but it can be performed after addressing the newborn's immediate needs, such as warmth.
Correct Answer is C
Explanation
A. Applying cold compresses is not indicated for pain and redness of the calf, which may
indicate deep vein thrombosis (DVT). Cold therapy is not recommended as it can worsen the condition.
B. Massaging the area is contraindicated in suspected DVT as it can dislodge a clot and lead to complications such as pulmonary embolism.
C. Elevating her leg helps to reduce swelling and improve venous return, which can alleviate symptoms of DVT and prevent further complications.
D. Flexing her knee while resting is not specifically indicated for the management of suspected DVT and may not address the underlying cause of pain and redness in the calf.
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